eRAD Request an Appointment  


Please note this form is for appointment requests. If you would like to schedule an appointment, please visit the link below. Through the link, you can schedule Ultrasound, Xray, Dexa, and Screening Mammograms only.

SCHEDULE AN APPOINTMENT


Please complete the following form and submit, note that all exam details and insurance information will be required before final scheduling is made.

Disclaimer: Please allow 24 business hours (M-F between 8am-6pm) for us to contact you as quickly as possible. This form is not a confirmation of an appointment. All insurance and ordering information will need to be received prior to appointment.

If your appointment is URGENT or STAT, please call our scheduling center at 855-455-8900.

XRAYS are walk-in's only. No appointment necessary.

The following locations provide X-RAY:
Annapolis (Defense) M-F 8-6 Sat 8-2
Bowie M-F 8-6
Glen Burnie M-F 8-6
Lutherville/Towson M-F 8-6
White Marsh M-F 9-5
Kent Island M-F 830-430

We look forward to accommodating your imaging needs, and Thank You for choosing Chesapeake Medical Imaging.


Patient Information
Last Name:
First Name:
Middle Name:
Birth Date:
Gender:
   
Phone Number:
Email:
Preferred Method of Contact: Phone     Email
   
Street Address:
Address Line 2:
City:
State:
Zip:
   
   
Insurance Information
Carrier:
Policy Number:
Group Number:
Policy Holder Last Name:
Policy Holder First Name:
Policy Holder DOB:
   
   
Imaging Services
Procedure Type:
Exam Details:
  Please specify exam details as indicated on the order, to include exam requested, laterality and if contrast is required.
   
Reason For Exam:
Ordering Medical Provider:
   
   
Appointment Info
Appointment Location:
Requested Exam Date:
  Limited Saturday hours are available for:
Annapolis (Defense Highway Location) (X-RAY, MG, MRI, CT) and Easton (MRI, MG)
Preferred Appointment Time:
   
Order Script:

***valid document formats are pdf, jpg, png, tiff, or gif***
  An Order/Script is not required at the time of your request, however an Order/Script is required from your medical provider at the time of your appointment.
   
 
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