Schedule an Appointment
If you would like to schedule an appointment at Beverly Hills Imaging, please fill in the following information:

Patient Name:
Primary Phone:
Secondary Phone:
Fax:
Exam Requested:
Reason for Exam:
Referring Doctor:
Insurance Carrier:
  WC  | PI  | Medicare  | Medi-medi  | Cash
Allergies:
Medications:
  Pregnant   |  Claustrophobic
Comments:
Physicians offices only
Patients next appointment w/ referring office:
Special Instructions:
Additional Reports to:
Images: None  | CD  | Key Images  | Web Access  | Film
Stat?
For CT exams needing intravenous contrast please provide:


Services | Referring Physicians | Schedule Appointment | Locations & Directions | Contact Us
Beverly Hills Imaging Medical Center, Inc.
145 South Doheny Drive
Beverly Hills, California 90211
310.550.5858