Skip to content
Pay Bill
|
Facility Login
Search for:
Home
About
Services
Who We Serve
LTC Facilities & Communities
Broaden your healthcare capabilities with budget-smart imaging & rapid results.
At-Home Concierge Services
Get healthcare at home with top-rated technologists & quality readings.
Correctional Facilities
Give inmates the care they need while eliminating security risks with on-site imaging.
Careers
Contact
Order an exam
House Exam
Facility Exam
Download Form
Email Form
Pay Bill
Facility Login
House exam
ricky@gcnymarketing.com
2020-11-10T19:27:18+00:00
House Call Order Request
Select Exam Type:
*
Please Select
X-Ray
EKG
Ultrasound
Pacemaker
Holter Monitor
Body Part
*
Patient Information:
Name
*
First Name
Last Name
Gender
*
Male
Female
SS Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Patient Home Address
*
Apt/Suite#
*
City
*
State
*
Zip Code
*
Symptoms
*
Patient Insurance Information
Select Insurance Provider
*
Please Select
Medicare
Medicaid
Other Insurance
Private Pay
Upload Insurance Information.
*
Policy Number
*
Patient / Family Connect Number
*
Ordering Physician Name
*
Physician Phone Number
*
Physician Fax Number
*
Email
*
Your Name
*
Preferred Exam Date
*
Date Format: MM slash DD slash YYYY
Upload Script
*
Consent
I will fax script or requisition.
Comments
*
Go to Top
