Request an Appointment

Request an Appointment

Patients

Use the form below to request a non-urgent appointment online.

Appointment Request Form

Please note: We cannot perform a diagnostic imaging procedure without a written requisition from your referring physician. Please contact your referring physician's office to obtain the proper requisition.

* = Required Fields

Choose your preferred location

Escondido (Services: MRI, CT, PET/CT, Ultrasound, Screening & Diagnostic Digital Mammography, DEXA – Bone Density Studies)

La Jolla (Services: MRI)

Oceanside (Services: MRI, CT Ultrasound, Vein Services, and Fluoroscopy)

* First Name

* Last Name

* Date of Birth (ex: 02/01/1967)

* Contact Phone

Alternate Phone

* How do you prefer we contact you?

Phone

Alternate Phone

May we leave a voicemail?

Yes

* Referring Physician

Type of exam requested

Type of Insurance

Insurance

HMO

PPO

Please read the information below before submitting this form to Regents Imaging.

Please note that information submitted on this form may not be secure or confidential. Detailed information regarding your exam and appointment with Regents Imaging will be discussed with you on the phone at the time your appointment is scheduled.

Simply fill out the form below and one of our staff will call or email you to schedule your exam. We will call or email you within 1 business day of your request. Please note your appointment is not scheduled until Regents Imaging has confirmed the receipt of information provided in this form. Response time for appointments requested online is only available Monday-Friday 8AM - 5PM, excluding holidays.

If we miss you or if you prefer to call us to schedule an appointment, please visit our locations page and call us at the center of your choice.