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Complete the form below, upload the necessary files, and submit your payment.

Contact Name*
Contact Email*
Office Name*
Office Address*
Office Phone Number*
Patient's Name*
Patient's Date of Birth*
Patient's Date of Injury*
Select your report type:
- Cervical | Second Opinion
- Cervical | Comparison
- Thoracic | Second Opinion
- Thoracic | Comparison
- Lumbar | Second Opinion
- Lumbar | Comparison
- Other
If you chose 'other' for report type, specify body part and type of report
How many reports are you requesting today?*
Please note that the fee is $250 per report/scan/body part. If there are more than two studies for each body part please choose the correct number of reports/scans/body parts. If you choose 'other' for more than 4 reports/scans/body parts, please specify how many reports/scans/body parts in the following field.
Special Instructions for the Radiologist
File*
Drop files here or

Max. file size: 256 MB.
Quantity*
Total
$0.00
Payment*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
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