PET/CT Scan Clinic Search Imaging Subcategory: Select Subcategory With Contrast Without Contrast With and Without Contrast Location: Max Price: $900 × Step 1 of 4 25% Consumer InformationHiddenClinic Name(Required) Your Name(Required) First Last Your Email Address(Required) Your Phone(Required)Date of Birth(Required) MM slash DD slash YYYY Sex assigned at Birth(Required) Male Female Height (ft)(Required) Weight (lbs)(Required) Do you have a referral from a Provider?(Required) I have a referral from a provider and can upload it now I do not have a provider referral for this imaging request and am self-referring for it. Imaging InformationImaging Study Type(Required)Select an Imaging ModalityMRICT ScanUltrasoundX-RayPET / CT ScanOtherBody Part Requested(Required) MRI Imaging Type MRI (Standard) MRA MRI Arthogram Contrast Without (No) Contrast With Contrast With & Without Contrast HiddenMRI Motivating Test Screening Diagnostic Biopsy CT Scan Type CT (Standard) CTA (Angiogram) CT Arthogram NotesAny additional information you wish to provide. Imaging Order InformationHiddenAre any of the conditions or situations applicable to you today?(Required) Claustrophobic Diabetic Migraines Seizure Requires a wheel chair (not ambulatory) Allergic to iodine or shellfish Had a creatinine lab test in the last 30 days History of cancer Do you have any metal in your body or a pacemaker? Is your imaging request part of a workman's compensation claim? None of the above Imaging Order or PrescriptionPlease upload the imaging order you received from your doctor. This will let us know who to contact for your imaging order. It can be a picture of the prescription from your phone. Drop files here or Select files Max. file size: 20 MB, Max. files: 5. Do you have a doctor or provider you'd like us to send the imaging results to? Yes No Authorization for Release of Medical Information to Your Provider and Expected Healthcare I want my imaging study reports and/or images to be sent to my provider.Signature for Medical Records ReleaseBy signing below, I acknowledge that I want I want my imaging study reports and/or images to be sent to the provider I listed. I authorize the clinic I receive my procedure at to release my medical imaging records to Expected Healthcare and to the provider I have listed.Provider Full Name Provider Phone NumberNotesAny additional information you wish to provide for your imaging order. Availability for Your AppointmentPlease provide at least one timeframe for each date that works for you.Preferred Date(Required) MM slash DD slash YYYY Alternative Date 1 MM slash DD slash YYYY Time Blocks(Required) Morning Afternoon Evening Time Blocks Morning Afternoon Evening NotesAny additional information you wish to provide. Create Expected Healthcare Account I would like to create an account in order to check on the progress of my appointment request.Username Password Appointment Consent(Required) I authorize Expected Healthcare to make an appointment on my behalf.I acknowledge the price listed is for self-pay, which means I do not need to use insurance. I acknowledge I will need to pay in full when I go to the clinic at the time of my procedure. I have read and agree (the patient has read and agrees) to the Expected Healthcare Terms & Conditions.
