Submit an Imaging Referral

Complete the form below to refer your patient for imaging at RecioMed. Our clinical team will coordinate scheduling and communicate results through your preferred channel.

Diagnostic imaging at RecioMed is provided by appointment only and is not an emergency or urgent care service. If your patient is experiencing a medical emergency, direct them to call 911 or go to the nearest emergency room.

Referring Physician Information

Physician First Name

Physician Last Name

Practice / Institution

Medical Specialty

Office Phone

Office Email

Patient Information

Patient First Name

Patient Last Name

Patient Date of Birth

Patient Phone

Imaging Modality

Urgency

Clinical Indication

Provide the clinical reason for the imaging order. Do not include full medical history in this field.

Additional Information

I confirm that I am a licensed healthcare provider and that I have authorization to submit this referral on behalf of my patient. I understand that RecioMed will contact my office to coordinate scheduling.