Complete the following form to schedule an appointment (Note: If test is a STAT, you must call to schedule.):

Patient Information
First		Md. Int.
Last
Date of Birth		Home Phone
Work Phone		SS#
Insurance		Auth./Claim#
Date of Injury
Referring Doctor Information
Referring Doctor		Phone
Next Appt. w/ Ref. Doctor		Patient Allergies
Exam Information
Please enter exam(s) details in appropriate boxes:
MRI		Open MRI*
MRA			*(West and North locations only)
CT Scan		Fluoroscopy
X-ray		IVP
Ultrasound		Echocardiogram
PET Scan		DEXA Scan
Mammography		Stereotatic Breast Biopsy
Film/Report Information:
	Call Report		Return Films with Patient
	Fax Preliminary Report		Additional reports to
	Written Report Only
	Deliver Film & Final Report		Patient to wait at until results are called
Location/Map/Directions Information
	NIC Open MRI (North) 1815 E. Lake Mead Blvd., Suite 113 N. Las Vegas, NV 89030 Get Directions --- Map		NIC Galleria (Southeast) 715 Mall Ring Circle, Suite 100 Henderson, NV 89014 Get Directions --- Map
	NIC Peccole Ranch (West) 9499 W. Charleston Blvd., Suite 100 Las Vegas, NV 89117 Get Directions --- Map		Spring Valley (coming soon) Rainbow Blvd., Suite 100 Las Vegas, NV 89118 Get Directions --- Map
Today's Date
Patient Appt. Date
Patient Appt. Time
Comments
Tell us how to get in touch with you:
Name		Email
Phone		Fax
	This patient is STAT.
	Please contact me as soon as possible regarding this matter.