Request an Appointment

Our online "Request an Appointment" feature is for patients who have a signed physician's order and would like to schedule a future appointment. This feature is not intended for same-day appointments.

To request an appointment at Coastal Diagnostic Imaging, please complete the form below and click "Submit." A scheduling representative will contact you to collect additional information and schedule your appointment.

• Do you have an order from your healthcare provider?
  Do you have an order from your healthcare provider?

  Yes No

• A signed physician's order is required to schedule an appointment.

  Please ensure you have a signed physician’s order to proceed with the Request An Appointment Form

• Your Information

• Your Name
• Your name

  Your name * First Last
  This field is required. Please enter a value.
• Your date of birth

  Your date of birth * / MM / DD YYYY
  Please enter a valid date. This field is required. Please enter a value.

• Your Contact Information

• Your email address *
  Confirm email address*
  Please enter a valid/confirmed email address.This field is required. Please enter a value.
• Primary phone number

  Primary phone number * - ### - ### ####
  This field is required. Please enter a value.Please enter a valid phone number.
• Alternate phone number

  Alternate phone number - ### - ### ####
  Please enter a valid phone number.

• Appointment Details

  What day and time would you like your appointment? We will do our best to find a time that works for you, but cannot guarantee the time you have requested.

• Location
  Jacksonville
• Date you would like to be seen

  Date you would like to be seen / MM / DD YYYY
  Please enter a valid date.
• Time you would like to be seen *
  Time you would like to be seen

  Anytime Morning Afternoon

  This field is required. Please enter a value.
• Type of study/modality (select one or more)
  *
  Type of study/modality (select one or more)
  

  CT Scan MRI Ultrasound X-ray

  This field is required. Please enter a value.

• Additional Information

• Who is your referring physician?

  Who is your referring physician? * First Last
  This field is required. Please enter a value.
• Additional Comments
• How did you hear about us? *
  Referring physician Online search Radio My insurance Company Family member / friend Community event I've been a patient before Other
  This field is required. Please enter a value.
• If other, please let us know how.

• PLEASE NOTE:

• If you elected to be contacted by email, please note that all correspondence from Coastal Diagnostic Imaging will be encrypted, and you will need to log into a secure portal to retrieve your messages. *
  If you elected to be contacted by email, please note that all correspondence from Coastal Diagnostic Imaging will be encrypted, and you will need to log into a secure portal to retrieve your messages.

  I agree

  This field is required. Please enter a value.
• Coastal Diagnostic Imaging takes the security and privacy of protected health information very seriously. We have implemented technical, administrative, and physical safeguards, which are designed to protect your information from unauthorized use and access. These safeguards are intended to ensure that our system is secure and that it meets our obligations under the HIPAA Security Standards Final Rule, as well as CCHIT Meaningful Use Security Requirements to specifically protect all electronic health information created or maintained by our certified Electronic Health Record technology. By providing your information and consent, you are authorizing Coastal Diagnostic Imaging to acquire certain data required to determine the scheduling necessities for the respective imaging exam you have selected on this request form. *
  Coastal Diagnostic Imaging takes the security and privacy of protected health information very seriously. We have implemented technical, administrative, and physical safeguards, which are designed to protect your information from unauthorized use and access. These safeguards are intended to ensure that our system is secure and that it meets our obligations under the HIPAA Security Standards Final Rule, as well as CCHIT Meaningful Use Security Requirements to specifically protect all electronic health information created or maintained by our certified Electronic Health Record technology. By providing your information and consent, you are authorizing Coastal Diagnostic Imaging to acquire certain data required to determine the scheduling necessities for the respective imaging exam you have selected on this request form.

  I agree
  This field is required. Please enter a value.
• Spam Protection. Please answer this simple question. *
  In the number 94847, what is the 5th digit? This field is required. Please enter a value.
•