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X-Ray Appointment Request

Thank you for choosing Baptist Health, we're here to help you book a convenient appointment for your imaging study. It's quick and easy!

By submitting this request form, you are authorizing Baptist to contact you using the methods you provide below.

Patient Information

First Name (required)^*

Last Name (required)^*

Email Address (required)^*

Primary Phone Number (required)^*

Primary Phone Type (required)^*

Secondary Phone Number

Secondary Phone Type

Date of Birth (required)^*

Select your birth month from the dropdown, then enter your birth day, followed by your birth year.

Select a Month

Day in two digits

Year in four digits

E.g. January 01, 1990

Referring Physician's Name (required)^*

Referring Practice (required)^*

Referring Physician Phone Number (required)^*

Do you currently have an order from your Physician? (required)^*

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