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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 Information to Submit Images to (First and Last Name)(Required.)

Provider First Name

Provider Last Name

Phone Number

Fax Number

Address Line 1

Address Line 2

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

Yes, please send me a copy of my imaging report.

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