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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: *
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 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
Please print and complete the following forms
Please review the patient privacy form below
Request for medical reports
Records requested by* Patient Physician/Physician’s office
Patient’s first name*
Date of birth *
Primary phone *
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
Your Name*
Preferred Date/Time*
Your Phone number*
Your email address*
Brief Description about the consult*
Home
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?*
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
(F) 832-821-9038
(P) 832-344-3512
Request an apppointment
(F) 832-821-9038(P) 832-344-3512 Request an apppointment