Request Appointment

Please review the following and make any appropriate updates. If you have an Order from your physician, click Upload File to attach to the appointment request. When done, read the Terms and Conditions, add any additional person(s), click the agree checkbox and Submit.

FACESHEET

Patient Information

Patient Name

Gender

DOB

Phone

Patient Email

Address Line 1

Address Line 2

City

State

Zip

Employee Information (Primary Insured)

Name

Insurance ID

Relationship
to Patient

Insurance ID

Group #

Employer

Service Information

Bundle Name	AE10 - CT Upper Extremity
What's Included	Performance of CT exam, including all facility charges; Interpretation and written report by a Radiologist; Contrast material; any supplies used in the performance of the exam and injection and copy of images.

Provider Information

MH Imaging - Milwaukee
7818 W. Layton Ave
Milwaukee, WI 53220
414-281-1490
414-281-1452
www.mhimaging.com

Referring Physician

Do you have a referring Physician?

Physician Name

Office Location

Office Phone

Authorization #

Diagnosis

Physician Order

Upload Physician Order

Select File

OR

Create Physician Order

Diagnosis

Ordering Provider Name

Order Entered by

Best Time to Call

Method of Communication

Special
Considerations

Terms and Conditions

I understand that by requesting an appointment that I am asking the provider to contact me in regards to that appointment at the number(s) and email(s) listed. I give that provider permission to request additional information from my referring physician, primary care physician and others in the continuum of treatment related to my appointment as determined by qualified medical professionals. I give providers contacting me permission to also speak with and , relationship and regarding this appointment request.

I agree with the above terms and conditions mentioned.