URPrecious Imaging Appointment Request

URPrecious Imaging Appointment Request

Choose your exam, share insurance and prior reports, and select preferred dates and times. Our staff will connect with you to streamline your process.
Full Name

First NameLast Name
Middle Name
Date of birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
How do you prefer to be contacted (check all that may apply)?
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Type of Exam/s Requested (select all that you may be interested to have/discuss with scheduling staff)

Other
Would you like our billing team to provide you with a cost estimate for these exams?
Do you have insurance?
Is your insurance Medicare?
Primary Insurance Subscriber First Name (if different from patient)
Primary Insurance Subscriber Last Name (if different from patient)
Date of Birth of Primary Insurance Subscriber (if different from patient)

MonthDayYear
Date
Upload Insurance Cards front and back (If Medicare, please upload supplemental insurance copies as well)

Please upload the front and back of your primary insurance card. If you have secondary insurance, also upload the front and back of that card.
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Do you have an order from your referring provider already?
Name of referring provider
Upload the order

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Do you have a provider who might be willing to give an order if our staff can reach out to them on the patient's behalf? Dr. Krishnan can be your provider, only if you have had a previous cryoablation treatment procedure with her.
Name of provider
Website or other info that can help us identify the provider
Please contact us at 602-878-7501 if you need assistance finding a referring provider. Alternatively, you may obtain a remote telehealth appointment through Diagnostic Orders Direct, allowing you to obtain an order for your exam/s. Diagnostic Orders Direct is an independent third-party service. URPrecious Imaging has no ownership interest in, financial relationship with, or compensation arrangement with them, and receives no payment for referrals. You are free to obtain your order from any licensed clinician of your choosing - this telehealth option is simply being shared as a convenience.
Upload Prior Imaging Reports and other documents

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Name/s of facilities/locations for the relevant prior exams (please let us know so we can obtain them before your appointment)?

Other
Preferred Appointment Date(s) and Time(s)
Additional Comments or Information
sysAccountName
sysAppointmentID
sysOrderID
sysPatientID
sysCareflowPrefillID
userrole
sysUserName
sysReportOutputTemplates
Should be Empty: