MRI Procedure Request Form

Please note that this MRI Procedure Request form is for letter of protection only. If the MRI is to be billed to the patient’s primary insurance then please call us for the standard Greater Waterbury Imaging Center scan order form.
  • Date Format: MM slash DD slash YYYY
  • Please enter the last four of the patient's social security number and we will call to get the full number.
  • Date Format: MM slash DD slash YYYY
  • Please enter valid email so that we can send you a copy of the form.
  • Please enter the Referring Physician Name. In order to approve the request, we will need to have the Referring Physician sign the form and fax to our office. We will contact you shortly to confirm the request.
  • This field is for validation purposes and should be left unchanged.

A Message To Our Patients on COVID-19 Please Read

To protect all of our patients and staff, if you are experiencing flu-like symptoms(fever, cough, shortness of breath), if you have traveled outside the country or on a cruise in the past 14 days, or if you have had close contact with any person, including healthcare workers, who are a lab-confirmed COVID-19 infected patient within the past 14 days, please call to reschedule your appointment.  Read more