Appointment Request

Radiology Affiliates Imaging offers convenient and expanded service hours including nights and weekends for most of our imaging procedures. Our scheduling department offers the convenience of being able to schedule an appointment for all your imaging needs at either our Hamilton or Lawrenceville locations. To schedule your appointment, please submit the form below and we will contact you by phone to confirm your appointment; or feel free to give us a call at (609) 585-8800.

Fields marked in red are required. Secondary exam information is not required.

Personal Information:

*First Name:

*Last Name:

*Daytime Phone:

Evening Phone:

Email:

*Date Of Birth:

*Referring Physician:

*Name of Insurer:

Appointment Information:

Appointment Location:

Primary Procedure Request:

Appointment Date – First Choice:

Preferred Time:

Secondary Procedure Request:

Appointment Date – Second Choice:

Preferred Time:

Any additional information you need to provide?