Desert Imaging Appointment Request Form

Schedule Your Exam with Desert Imaging

You have two convenient options to schedule your exam:
1. Call Our Scheduling Department: Speak directly with a Patient Care Coordinator by calling us at 915-577-0100.
2. 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.
- Fields marked with an asterisk (*) are required.
- 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.
Appointment Request Form
Patient Full Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Contact Number*
Please enter a valid phone number.
Patient Email Address*
example@example.com
How will you be paying?*

InsuranceSelf Pay
Do you have an order from your referring physician?*

YesNo
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:

Cancelof
PHYSICIAN INFORMATION

Please provide the information about your referring physician:
Physician Full Name

First NameLast Name
Physician Email
Physician Phone Number
Please enter a valid phone number.
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select the service(s) you are requesting:*

Screening MammogramDiagnostic MammogramUltrasoundMRI / MRACT / CTAPET/CTNuclear MedicineX-RayBone Density / DEXAElectrocardiogram (EKG)Other
Please Indicate which service(s) you are requesting:
Please indicate the location you prefer:

No PreferenceWEST - 122 W. Castellano 79912CENTRAL - 7812 Gateway East 79915East - 1727 Lee Trevino 79936Far East - 3080 Joe Battle 79938Horizon City - 13650 Eastlake 79928
Please indicate the day(s) of the week you prefer:

No PreferenceMondayTuesdayWednesdayThursdayFridaySaturday
Morning or Afternoon?

No PreferenceMorningAfternoon
If you have any special scheduling considerations, please note them in the box below:
sysAccountName
sysAppointmentID
sysOrderID
sysPatientID
sysCareflowPrefillID
userrole
sysUserName
Should be Empty:

Appointment Request Form

PHYSICIAN INFORMATION