Schedule an Appointment

Patient Information:

Your Name*

Date of Birth*

Requested Appt. Date*

Requested Appt. Time*

Services requested:

  CT

  MRI

  Nuclear Medicine

  PET/CT

  DEXA

  Mammography

  Digital X-ray

  Ultrasound

  Interventional Radiology

  Not sure

Address:

Street*

Appt #

City*

State*

Zip*

Phone*

Insurance Information:

Insurance provider

Insurance id

Insurance group

Insurance guarantor

Provider Information:

Provider Name*

Provider Phone*

  Will fax order (623-825-8299)
  Will email order (scheduling@sunradiology.com)
  I will hand carry order to my appointment

Contact Information:

Contact Name*

Phone Number*

Email*




Patient Information:

Your Name*

Email*

Date of Birth*

Appointment Information:

Scheduled Appointment Date*

Scheduled Appointment Time*

Reschedule to Date*

Reschedule to Time*

Reason for rescheduling or cancellation:

  Conflict on date/time will reschedule at a later date

  Sick/Hospitalized – will reschedule at a later date

  Do not want this exam

  Exam was completed at another facility