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Northwest Primary Care Imaging Request Form

To request images from Northwest Primary Care, please complete the form below and click "Submit." Please allow 48-72 hours to complete the request.

1.Patient Name:(Required.)

2.Patient Date of Birth(Required.)

Please enter your date of birth in the field below.

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

3.Date of Service(Required.)

Please enter the date of service for the images you are requesting.

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

4.Images Requested(Required.)

5.Provider Name and Phone Number to send imaging report to:(Required.)

Provider First Name

Provider Last Name

Provider Phone Number

6.Additional Contact Information for Provider (Optional)

Provider Fax Number

Address Line 1

Address Line 2

7.Would you also like to request a copy of your imaging report?(Required.)

Yes, please send a copy of the imaging report.

No, please do not send a copy of the imaging report.