Request an Appointment - NCDI

Do you have a signed physician's order?

Do you have a signed physician's order? Yes No
Your Information
Your Name *
Insurance Carrier *
The Best Way To Reach You
Preferred method of contact *

Preferred method of contact Email Phone
Your email address *

Confirm Email Address *
Primary phone number Primary phone number * - ### - ### ####
Alternate phone number Alternate phone number - ### - ### ####
Appointment Details - North Carolina Diagnostic Imaging

What day and time would you like your appointment? We will do our best to find a time that works for you, but cannot guarantee the time you have requested.
Location *
Date you would like to be seen Date you would like to be seen * / MM / DD YYYY
Time you would like to be seen *

Time you would like to be seen Anytime Morning Afternoon
Additional Information
How did you hear about us? *
If other, please let us know how.
PLEASE NOTE:
If you elected to be contacted by email, please note that all correspondence from North Carolina Diagnostic Imaging will be encrypted, and you will need to log into a secure portal to retrieve your messages. *

If you elected to be contacted by email, please note that all correspondence from North Carolina Diagnostic Imaging will be encrypted, and you will need to log into a secure portal to retrieve your messages. I agree
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