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Thank you for choosing Western Imaging for your exam.

This pre-registration form is designed to save you time on the day of your exam. Please complete and submit the form at least one day prior to your exam.

We will still need to copy your insurance card on the day of the exam as well as ask you for your Doctors orders for verification purposes. Please be sure to alert our staff that you have pre-registered when you come in to assure you receive the benefit of pre-registering.

All areas marked (*) are required fields.

 
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Pre Register For Your Exam
Learn More About Your Exam
 
  PATIENT INFORMATION
Last Name*
First Name*
  Work Phone
Primary Phone*
  Email Address 
 
  Street Address*
City*
 
State*
Zip*
Gender
Male      Female    
 
Date of Birth (MM/DD/YYYY)
 
  Employer Name
Employer Address
  City
State
Zip
  Referring Physician
Injury Date (MM/DD/YYYY)
 
Date of Your Exam (MM/DD/YYYY)
 
Exam Location:
Marina del Rey   
     
  RESPONSIBLE PARTY (Name of insured)
Last Name
First Name
  Phone
Employer
  Street Address
City
 
State
Zip
 
     
  PRIMARY INSURANCE
Insurance Company
 
  Phone
 
  Street Address
City
 
State
Zip
 
  Subscriber/Policy Holder
Relationship to Patient
     
  SECONDARY INSURANCE
Insurance Company
 
  Phone
 
  Street Address
City
 
State
Zip
 
  Subscriber/Policy Holder
Relationship to Patient
     
  ATTORNEY INFORMATION (IF APPLICABLE)

Attorney's Last Name

Attorney's First Name
  Phone
 
  Street Address
City
 
State
Zip
 
     
  SUBMIT YOUR INFORMATION


Click below to submit your data and you'll receive confirmation of receipt.
If necessary, we will contact you for additional information.

    
 

 

 

 
 
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