Imaging Request Form - Providence Imaging Center Alaska
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Request Your Images
You can request a digital copy of your exam be delivered by email, or on CD for pickup or mailing.
1.
Patient First Name
*
2.
Patient Last Name
*
3.
Patient Birthdate
*
4.
Exam Date
5.
Type of Exam
*
-- Please Select --
X-Ray
MRI
Mammogram
Ultrasound
CT Scan
PET-CT Scan
All Exams of that Date
Other (not listed)
6.
Are you the Patient?
*
Yes
No
7.
Provider Contact Name (if applicable)
8.
Requester Phone
*
9.
Requester Email
*
10.
Image Delivery Method
*
-- Please Select --
Email to Patient (1 business day)
Pickup at Anchorage PIC
Mail to Patient
Mail to Other (specify below)
11.
Mailing Address
*
12.
City
*
13.
State or Province
*
14.
Zip or Postal Code
*
Submit Request