Nuclear Medicine Pre-Registration

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Nuclear Medicine Pre-Registration

Welcome to Southwest X-Ray‘s Nuclear Medicine Scheduling Agreement page. This form is a pre-requisite to your Nuclear Medicine exam at one of our El Paso locations. By using this form, this will make the appointment run smoother and also the billing process. Please fill out the forms below in their entirety and in the order they are presented. If you have any questions, you can contact us at (915) 544-7300!

Your Name(*)

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D.O.B.:

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Address:

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Relationship to Patient:

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Your Email(*)

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Exam:

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Comments:(*)

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Doctor:

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Insurance Company:

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Insurance Number:

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I Agree(*)

I hereby request and authorize the technologist of Southwest X-Ray to utilize ISOTOPE dye in accordance with the instructions of the referring physician and/or radiologist. I have been informed by the technologist and/or physician of the nature of the procedure, the indication for the utilization of ISOTOPE dye to help facilitate a specific diagnosis. I also understand that the specific ISOTOPE was ordered for me and my insurance will be billed regardless of whether the exam is complete. My insurance will also be billed if I don’t show up to my appointment.

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esignature(*)

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About Southwest X-Ray

Here at Southwest X-Ray we are dedicated to helping people of all ages with a range of diagnostic imaging services for early diagnosis and improved health care. Our services include X-Rays, Nuclear Medicine, Ultrasound, Mammography, Bone Density (DXA Scan, DEXA Scans), MRI, CT-Scans and now Molecular Breast Imaging.

We currently have 5 Southwest X-Ray locations in El Paso, Texas near you! Our newest location is in Downtown El Paso!

Call Us Now at (915) 544-7300