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Toll Free: 844-551-6910
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Referral Form

This form is for your doctor to fill out for medical insurance submission. You can fill out the form two different ways.

  1. Referral Form fill it out and bring with you at the time of your appointment or email to: scheduling@premiermedicalimaging.net.
  2. Complete our online referral form and hit submit.

Send us mail

Patient Forms

Choose the forms from below and download any appropriate forms.

Download Adobe Acrobat Reader
MRI FORMS

  • pdf-48_32
    MRI Screening
  • pdf-48_32
    MRI Abdomen Body
  • pdf-48_32
    MRI Cervical Thoracic
  • pdf-48_32
    MRI Foot and Ankle
  • pdf-48_32
    MRI Hand, Wrist & Arm
  • pdf-48_32
    MRI Head and Brain
  • pdf-48_32
    MRI Knee
  • pdf-48_32
    MRI Pelvis
  • pdf-48_32
    MRI Shoulder and Arm
  • pdf-48_32
    MRI Soft Tissue

CT FORMS

  • pdf-48_32

    CT Body
  • pdf-48_32

    CT Bone Density
  • pdf-48_32

    CT Head
  • pdf-48_32

    CT Lung Screening
  • pdf-48_32

    CT Sinus

MAMMOGRAM FORM

  • pdf-48_32

    Mammogram

 

Our technologists are certified and registered through the American Registry of Radiologic Technologists and meet the ethics and continuing requirements established.

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Serving these and surrounding areas:

MINNESOTA
  • Detroit Lakes

NORTH DAKOTA
  • Fargo



NEBRASKA
  • Norfolk

Headquartered in North Dakota:

5257 27th Street South
Suite 101
Fargo, ND 58104

Call Toll Free: 844-551-6910

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