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*

    Refrence Dr name and Phone number*

    Type of Scan*

    Insurance Type*

    Primary Insurance:

    Name

    Policy or Claim Number

    Group Number

    SecondaryInsurance:

    Name

    Policy or Claim Number

    Group Number

    Alternate:

    Name

    Phone Number

    Accident date


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