To order an exam please fill out this form and press submit (at the bottom)- or download, fill out and fax this document.
PLEASE CALL (727) 669-5525 TO CONFIRM ORDER WAS REVCEIVED.
STATs after 8pm must be called-in.

* = required

General Patient Info

Patient Last Name *

Patient First Name *

SSN *

DOB *

Medicare HIC *

Medicaid/Other: *

Pt Phone:

Symptom/Diagnosis for Exam(s) *

Gender

Male

Female

Film/CD Delivery (optional):

Choose one:

Film

By when:

To where (Dr):

Telephone/Verbal order received by the physician/ARNP listed below:

Physician/ARNP Ordering Exam:

Last: *

First: *

Electronic Signature: I certify this patient is facility/homebound due to the conditions listed above.

Physician name:

Date* :

Check box to verify electronic signature is from the physician listed.

Electronic Signature: I certify the ordering Physician/ARNP orders for these tests are on file at the facility.

Authorized Representative name:

LPN

Date* :

Check box to verify electronic signature is from the nurse or authorized representative.

General Patient Info

X-Ray

Ultrasound

Portable Services Requested Due To Patient's Medical Condition(s) Listed. Check All That Apply:

Film/CD Delivery (optional):

Telephone/Verbal order received by the physician/ARNP listed below:

Electronic Signature: I certify this patient is facility/homebound due to the conditions listed above.

Electronic Signature: I certify the ordering Physician/ARNP orders for these tests are on file at the facility.