WARNING!

Do not fill out this form unless 1) you have already sent us your provider referral and 2) you have your insurance information ready. We will need this to determine authorization needs. Please send RX to the email or fax below, or bring into our office. (CT Calcium Score and CT Low Dose Lung Screening do not need an RX to schedule).

email: goodhealth@hdielko.com
fax: 775.621.5801

office address: 2110 Idaho St., Elko, NV 89801

Make An Appointment

Please fill out the form below to request an appointment with High Desert Imaging. An HDI representative will follow up with you to confirm your information and schedule your appointment date and time. To expedite the check-in process, you can download and print patient forms before your appointment to bring with you the day of your exam.

Name

First Name

Last Name

Date of Birth

Phone

(###)

###

####

Preferred Time to Call

Preferred Exam Date

Preferred Exam Time

Exam Requested

All exams excluding cash-pay specials for Lung Cancer Screening and Cardiac Calcium Scoring will require a doctor's referral.

Do you have previous studies of the body part you want imaged?

If your answer is yes, and you have had a previous exam or x-ray of the body part you're requesting an exam for, please fill out an HDI medical release form and email your form to us prior to your appointment or bring it with you to your appointment.

Yes

Do you have a doctor's order for this exam?

For most exams a doctor's order is required to schedule an appointment with HDI. You can request your doctor's order be faxed to our office at 775.621.5801.

Yes

No (DO NOT SUBMIT THIS FORM UNTIL YOU HAVE THAT)

Primary Insurance Carrier

If you are a self-pay customer not billing to insurance, please indicate such.

Your Referring Physician's Name

Comments, Notes & Questions

WARNING!

Make An Appointment

High Desert Imaging

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