Lodaer Img

Prescription & Imaging Referral Form

For referring providers

Refer a patient for diagnostic imaging at any of our five Southern California locations. Download the referral form, complete the required fields, and send it back to get your patient scheduled.

How it works

  1. 1

    Download the form

    Use the referral form on the right. It’s the same form for all five locations.

  2. 2

    Complete the required fields

    Fill in the patient and referral details:

    • Patient name and contact information
    • Type of imaging (MRI or X-Ray) and the body part or region to be imaged
    • Clinical indication or reason for the referral
    • Referring provider name, contact, and signature
  3. 3

    Send it back

    Return the completed form to get your patient scheduled.

    Email or fax the completed form to the facility where you’d like your patient scanned:

    Questions? See our locations for phone numbers and directions.
View our locations
Request an appointment

The referral form

Download Prescription Form

Can't see the form above? Download the PDF instead.