Diagnostic Imaging Centers

Online Patient Scheduling Request Form

Please complete below information and then click "submit."

Your information will be forwarded to scheduling
and you will be contacted for your appointment.
If patient’s need is urgent please call scheduling at 913-344-9989 or 816-444-9989.

*Denotes required information

Patient Last Name*:

Patient Middle Initial:

Patient First Name*:

Patient Date of Birth*: format: 01/01/2001

Phone # to reach patient*: format: xxx-xxx-xxxx

Preferred time to call:

Patient Status:

Exam*:

Name of Ordering Physician*: format: First Name Last Name

***You will need to provide an order from your physician unless you are scheduling a screening mammogram, coronary calcium screening, or CT Body Scan.

To help us distinguish between emails submitted by individuals and those automatically entered by software robots, please type the *case-sensitive* skewed letters shown here into the box below.

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