Request Images or Reports Patient Info First Name M.I. Last Name DOB DOB: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec DOB: Day Day12345678910111213141516171819202122232425262728293031 DOB: Year Year19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Contact Info Address Address Apt/Suite City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Email Email Confirm Email (This will only be utilized for confirmation that we have received the online request) Please Provide the 10 digit primary phone number to contact you during daytime hours. Any additional phone numbers we may use should also be listed. Phone 1 Phone 1 Type Home Cell Work Phone 2 Phone 2 Type Home Cell Work Phone 3 Phone 3 Type Home Cell Work Voicemail Yes No May we leave a voicemail message if prompted? Request Exam Image(s) Requested Date(s) of Service Unless you indicate the exact date(s) of service we must contact you to confirm which images you are requesting. Format In what format do you need your images or reports? CD (DICOM) Report Only PowerShare Select Powershare/Pickup/Delivery Location - None -Patient Resource CenterMail to patient's address on fileSend directly to my physicianPowersharePowerShare to email addressBreast Center Of FairfaxCentreville Imaging CenterFairfax Diagnostic Imaging CenterFairfax Radiology Center of BallstonFairfax Radiology Breast Center of LoudounFairfax Radiology Center at HeritageFairfax Radiology Center at PatuxentFairfax Radiology Center at PembrookeThe MRI CenterInova Fair Oaks HospitalInova Loudon HospitalProsperity Imaging CenterProsperity PET CTReston/Herndon Breast CenterReston/Herndon Imaging CenterSpringfield Imaging CenterFairfax MRI/Imaging at TysonsThe Vein and Vascular CenterVienna Imaging CenterWoodburn Diagnostic Center Please check the location for hours of operation. Powershare to Email Physician Requesting the Images Physician First Name M.I. Physician Last Name Physician Phone Just enter the 10 digits of the number without spaces or dashes. Physician Address Address Suite City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Comments Who will pick up the images? To assure your privacy, all individuals picking up images will be required to provide a picture ID Pickup Patient Other Other Pickup If other, please provide the name Agreement I understand Fairfax Radiology will not release my images to anyone other than myself without written authorization from me. CAPTCHA Leave this field blank