Shields Online Order

SHIELDS ONLINE ORDER

Patient Information

First Name: *

Last Name: *

Date of Birth: *

Gender: *

M F X

Mobile: *

Alternative:

Insurance Information

Private Health Auto Worker's Comp Self Pay

Primary Insurance

Insurance Company: * Insurance missing?

Subscriber ID: *

Authorization:

Secondary Insurance

Insurance Company: Insurance missing?

Subscriber ID:

Authorization:

Auto Insurance

Insurance Company: * Insurance missing?

Claim ID: *

Authorization:

Adjuster Information:

Private Insurance

Insurance Company: * Insurance missing?

Subscriber ID: *

Authorization:

Attorney Information

First Name:

Last Name:

Street One:

Street Two:

City:

State:

Zip Code:

Worker's Comp Insurance

Insurance Company: * Insurance missing?

Claim ID: *

Authorization:

Adjuster Information:

Private Insurance

Insurance Company: * Insurance missing?

Subscriber ID: *

Authorization:

Attorney Information

First Name:

Last Name:

Street One:

Street Two:

City:

State:

Zip Code:

Exam Information

Exam Modality: *

Priority: *

MRI PET/CT

Routine STAT

Stage: *

Isotope:

Exam Location: *

Filter By Technology:

All 1.2T High Field OPEN-SIDED 1.5T High Field 1.5T High Field OPEN-BORE 3T High Field 3T High Field OPEN-BORE

Clinical Detail

ICD10: *

Exam Reason:

Procedure:*

Clinical Notes & Attachments

* Supported file formats are: PDF, TIF, TIFF, JPG, JPEG, PNG

Provider Information

*By typing my name below, I am electronically signing this online order form.

First Name: *

Last Name: *

NPI: *

Provider's Mobile:

Office Location (city/town): *

To receive an order confirmation, first enter the preferred email address(s), then click 'submit'. On the next page, you must click "email confirmation".

Provider's Email:

Office Contact Email:

Shields will provide information related to appointments, experience, results and other information using the email and mobile provided. We are committed to your privacy and will not share your information with any third party.