Please fill out the following online form. Once we receive your request, we will contact your patient directly within 24 hours to schedule their appointment. Patient Name * Patient Date of Birth Requested time to be seen: 1 to 2 days 3 to 5 days If requested to be seen immediately, please call our office at (319) 383-3606. Body part to be imaged (If the patient has a pacemaker, pacer wires, defibrillator, cerebral or arterial aneurysm clips, they may not have an MRI.) Is the patient claustrophobic? over 350 lb.? diabetic? Has the patient worked with metal? Yes No If YES to any of the above, please call 319-338-3606 and speak with a scheduler. Symptoms History Has this procedure been pre-certified? Yes No If yes, please provide pre-cert# Name of Physician Physician NPI Fax report to Dr. Fax # CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Math question * 6 + 7 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.