Request an Appointment

Please use this form to request an appointment with Charter Radiology.

Patient's Name
First Last
Patient's Date of Birth
MM
DD
YYYY
Patient's Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Patient's Phone
Patient's Email
Insurance Provider (Name of Company)
Referring Physician's Name
Type of Imaging
- MRI
- CAT SCAN (CT)
- X-RAY
Preferred Appointment Date
Preferred Appointment Time

: HH

MM
Preferred Appointment Location
- Columbia
- Reisterstown
- First Available / No Preference
Comments
Phone
This field is for validation purposes and should be left unchanged.

Charter Radiology