Desert Imaging Appointment Request Form

Schedule Your Exam with Desert Imaging

You have two convenient options to schedule your exam:

Call Our Scheduling Department: Speak directly with a Patient Care Coordinator by calling us at 915-577-0100.
Complete the Exam Request Form Below: Fill out the form as thoroughly as possible and press the “Submit” button.

Important Information for Completing the Form:

A Patient Care Coordinator will review your submission and contact you within 1-2 business days to confirm the date, time, and location of your exam.

Please note that the date, time, and location of your exam are not confirmed until a Patient Care Coordinator contacts you.

You must have a medical provider’s referral or order to receive a medical imaging exam.

Once the form is submitted correctly, a confirmation message will appear on your screen.

Thank you for choosing Desert Imaging! We are committed to providing you with exceptional care.

Patient Full Name

First NameLast Name

Patient Date of Birth

Date

Patient Contact Number

Please enter a valid phone number.Format: (000) 000-0000.

Patient Email Address

example@example.com

How will you be paying?

Do you have an order from your referring physician?

A physician's referral/order is required for all services. Please contact your medical provider to request a referral.

If you have your referral, please upload it here:

Physician Full Name

First NameLast Name

Physician Email

Physician Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please select the service(s) you are requesting:

Please Indicate which service(s) you are requesting:

Please indicate the location you prefer:

Please indicate the day(s) of the week you prefer:

Morning or Afternoon?

If you have any special scheduling considerations, please note them in the box below:

sysAccountName

sysAppointmentID

sysOrderID

sysPatientID

sysCareflowPrefillID

userrole

sysUserName

Appointment Request Form