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Request an appointment

Please complete the form below and we will contact you within 1 business day to confirm your appointment date and time.

Are you a: PatientPhysician or Physician’s office

Patient’s first name *

Patient’s last name*

Date of birth*

Primary phone*

Email *

Do you have an MRI order?*YesNo

Attach order form

Type of exam needed (check all that apply): *Cardiac ImagingGeneral MRICPETLiver Health ImagingOther

Preferred date*

Preferred time: *

Request imaging report

If you need images or reports from a past exam, our support team at Live Healthy Imaging is ready to help! Please complete the request for medical records form or call our office to submit your request. Please allow 48 hours for requests to be processed and 5 business from your date of service for records to become available.

Records requested by: *
PatientPhysician’s office

Patient’s first name *

Patient’s last name *

Date of birth: *

Primary phone: *

Email: *

Please select requested format:*
Digital copy onlyPaper copy onlyDigital and paper copy

Records are to be: * Picked up by patient at Live Healthy ImagingPicked up by authorized representative at Live Healthy ImagingMailedFaxedSent electronically/email

Records requested: *
Cardiac imagingMRICPETLiver Healthy Imaging

Patient forms

Please print and complete the following forms

Patient screening sheet (English)
Patient screening sheet (Spanish)
Patient Financial Responsibility
COVID Questionnaire (Spanish)
COVID Questionnaire (English)

Please review the patient privacy form below

Patient Privacy Notice

Order Forms

Non-cardiac MR order form
Cardiac MR order form

Request Imaging Report

Request for medical reports

If you need images or reports from a past exam, our support team at
Live Healthy Imaging is ready to help! Please complete the request for medical records form or call our office to submit your request. Please allow 48 hours for requests to be processed and 5 business from your date of service for records to become available.

Records requested by*
Patient Physician/Physician’s office

Patient’s first name*

Patient’s last name*

Date of birth *

Primary phone *

Email *

Records are to be Picked up by patient at Live Healthy ImagingPicked up by authorized representative at Live Healthy ImagingMailedFaxedSent electronically/email

Please select requested format * Digital copy onlyPaper copy onlyDigital and paper copy

Name of person or entity authorized to receive information *

Address *

City/State/Zip *

Fax # *

Records requested *
Cardiac imagingMRICPETLiver Healthy Imaging

HIPAA release signature *

I agree to the privacy policy

Request consult

Your Name*

Preferred Date/Time*

Your Phone number*

Your email address*

Brief Description about the consult*

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Reason for Contact*BillingScheduling an appointmentRequest images/reportResearch and partnershipRequest a consultGeneral inquiriesOther

Live Healthy Imaging

6565 West Loop South, Suite 100
Houston, Texas 77401

(P): 832-344-3512
(F): 832-821-9038
(E): info@livehealthyimaging.com

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Schedule an Appointment

Do you have a doctor’s order for a test?*YesNo

Full Name*

What type of test?*MRICPETCT ScanOthers

Mobile*

Email*

Your preferred date and time for test?*

Request on appointment

Thank you for your Appointment.

Your appointment schedule number is #LHI20210125001

We will try to accommodate your requested time and date; Live Healthy Imaging Consultants will contact you from our office