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Physician Imaging Request Form

For Medical Professionals Only

At this time we cannot accept the following procedure orders online: arthrograms, aspirations, biopsies, localizations, stress tests, or hysterosalpingograms (HSGs). Click here to select and print out the necessary form.

Please call (310) 423-8000.
Note: * indicates required fields.

* Patient Last Name:
* Patient First Name:
* Date of Birth: (mm) (dd) (yyyy)
MRN: (if available) (optional)
Patient Phone Number
(9 am - 5 pm):

area code 		 -    (optional)
phone number
If Patient is already scheduled:  
Authorization Number:  (optional)
Reservation Number:  (optional)
Date of Exam:  (optional)
Check-in Time:  (optional)
Exam Time:  (optional)
 
* Exam(s) Requested (please select at least one or more):
 CT
 Cardiac
 MRI
 Mammography
 Nuclear Medicine
 PET Brain
 PET/CT
 Ultrasound
 Vascular
 X-Ray / Fluroscopy
 
* Clinical Signs and Symptoms:
Comments:
 
Physician Details:
* Requesting Physician Last Name:
* Requesting Physician First Name:
* NPI or Cedars-Sinai ID (Number):  
* Phone Number:

area code		  -  
 
phone number
Fax:

area code		  -  
 		  (optional)
phone number
Email:  (optional)
Call Immediate Report (Number):  (optional)
 
Send Duplicate Copies:
Send Duplicate Report(s) to Dr.:  (optional)
Phone Number:

area code		  - 
 		  (optional)
phone number
Fax:

area code		  -  
 		  (optional)
phone number
 
Send Duplicate Report(s) to Dr.:  (optional)
Phone Number:

area code		  -  
  (optional)
phone number
Fax:

area code		  -  
 		  (optional)
phone number
 
IMMEDIATE WET READ RESULTS REQUESTED:  
Call Immediate Report:

area code		  -  
 		  (optional)
phone number
 
By clicking the Submit Request button below, you will be sending your request to the
S. Mark Taper Foundation Imaging Center at Cedars-Sinai.
Please review your information before submitting this request.
After you submit you will receive an encrypted copy of your order at the email address provided above.
To view your confirmation, please click on the link in the email, create a password and retrieve your confirmation.
You only need to create a password the first time you use the system.
 
   
Version: 1.5.6