Appointment Request Form

Use this form for non-urgent appointments only.

For urgent appointments within 24 hours, please contact us by phone at
(609) 261-4500 x1.

An asterisk (*) indicates required information

First Name *	Please enter your first name.
Middle Initial	Invalid Input
Last Name *	Please enter your last name.
Address	Invalid Input
City	Invalid Input
State	Invalid Input
Email *	Please enter a valid email address.
Patient's Date of Birth *	Please enter the patient's date of birth.
Primary Phone *	HomeCellWork Please choose your primary contact.
*	Please enter your area code and phone number.
Alternate Phone	HomeCellWork Invalid Input
	Invalid Input
Best Time to Call	Invalid Input
	Appointment Information
	Hold the control key down when selecting exams, if more than one is needed. Please choose all exams needed.
Type of Exam	Invalid Input
Patient Status *	Invalid Input
Preferred Day for Appointment *	Please select your preferred day for the appointment.
General Comments/Questions	Invalid Input
	Larchmont Medical Imaging will not be held responsible in the event your electronic message is not transmitted due to technical problems related to this site or to the hosting server. All personal identifying information is encrypted and your message will not be internally or externally forwarded to other parties. The information will solely be used by Larchmont Medical Imaging. If you do not accept the terms of this disclaimer, you will not be able to process your request online.
Terms & Conditions *	I Agree Please check the box that you agree to the terms and conditions stated on the online form.

Your request will be processed within 24 hours, during normal business hours, Monday - Friday, 8:30 a.m. to 5:00 p.m., excluding holidays. If you do not hear from us within that timeframe, or if you have questions, please contact our Scheduling Department at (609) 261-4500 x1.