Please complete and send for a free estimate.

Please complete and send for a free estimate.

Please complete and send for a free estimate.

  • Your Information

  • Do you have an order? *
    Do you have an order?
  • Are you already scheduled with us? *
    Are you already scheduled with us?

  • Please contact our facilty for any questions regarding an existing appointment

    You can find a list of our locations here.

  • Your name Your name *

  • Insurance Information

  • Will you be filing insurance? *
    Will you be filing insurance?
  • Your date of birth Your date of birth / /
  • Phone number for eligibility and benefits Phone number for eligibility and benefits - -

  • Exam Details

  • The Best Way To Reach You

  • Preferred method of contact *
    Preferred method of contact
  • Primary phone number Primary phone number * - -
  • Alternate phone number Alternate phone number - -

  • Additional Information

  • PLEASE NOTE:

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

  • Florence MRI & 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 Florence MRI & Imaging to acquire certain data required to calculate your estimated financial responsibilities related to the respective imaging exam you have selected on this request form. *
    Florence MRI & 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 Florence MRI & Imaging to acquire certain data required to calculate your estimated financial responsibilities related to the respective imaging exam you have selected on this request form.

  • If yesterday was Monday what day is today?