Office & Patient Guide

 

Office & Patient Guide  >  Request an Appointment

Request an Appointment

This online appointment request form may be used to notify Washington Radiology Associates that you would like to schedule a non urgent appointment. Please note that information submitted on this form may not be secure or confidential. Detailed information regarding your exam and appointment with WRA will be discussed on the phone at the time of scheduling.

Your request will be processed during normal business hours, Monday - Friday, 7:30 am – 6:00 pm, excluding holidays.

A WRA scheduling representative will attempt to contact you during the next business day. To ensure the accuracy and completeness of your request, please have the order from your physician and your insurance card available for reference.

* Indicates Mandatory Fields

I would like to request an appointment for: * Mammogram Screening Other Exam
Please enter the exam your physician ordered:
Your Full Name: *
Address:
City / State / Zip:
Date of Birth
(Ex. dd/mm/yy):
Email Address:
Please Provide a 10 digit primary phone number to contact you during daytime hours. Any additional phone numbers that we may use should also be listed.
Phone 1: * Home   Cell   Work
Phone 2: Home   Cell   Work
Phone 3: Home   Cell   Work
May we leave a voicemail message if prompted? * Yes   No
Our schedulers are available to contact you Monday-Friday between the hours of 7:30 am – 6:00 pm, excluding holidays.
Select the best time of the day to reach you:
Specific Time:
Referring Physician's Information
Full Name: *
Office Phone: *
Office Address:
City / State / Zip:
Please indicate the office location you would like for your appointment. We will make every effort to accommodate your request.
*Appointment Location:
Please indicate the day and time preference for your appointment. We will contact you with our first available appointment and make every effort to accommodate your request.
Appointment Day:
Appointment Time:
Comments: