Park Place MRI’s response to COVID-19

Schedule Appointment

    Name*

    DOB*

    Sex*

    MaleFemale

    Weight*

    Claustrophobic*

    YesNo

    Language Spoken*

    Cell Phone Number*

    Body Part to be Scanned*

    Email

    Referring Dr Name and Phone Number*

    Type of Scan*

    Insurance Type*

    Primary Insurance:

    Name*

    Policy or Claim Number*

    Group Number

    Secondary Insurance:

    Name

    Policy or Claim Number

    Group Number

    Attorney Information for Accident Cases:

    Name

    Phone Number

    Accident date




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