You must have JavaScript enabled to use this form. Use Inova Health System's online appointment request form to notify us when you would like to schedule a non-urgent appointment for an imaging (radiology) exam. An Inova Central Imaging Scheduler will attempt to contact you within the next business day. To assure an accurate and complete scheduling process, please have the order from your physician and your insurance card available for reference. * Indicates required field I would like to request an appointment for: - Select -Screening MammogramOther Radiology Imaging Exam Write the procedure as it is listed on your prescription from your physician in the box below: Ordering Physician Name Ordering Physician Phone First Name (Patient) Middle Initial (Patient) Last Name (Patient) Address Address Address 2 City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Home Phone Work Phone Cell Phone Email Address Best phone to be reached at - None -HomeWorkCell May we leave a voicemail message if prompted? - None -YesNo Specify the best time to reach you Specify the most convenient Inova location: (List of locations) Locations - None -Inova Alexandria HospitalInova Fairfax HospitalInova Fairfax Hospital for ChildrenInova Fair Oaks HospitalInova Loudoun HospitalInova Mount Vernon HospitalInova HealthPlex – AshburnInova HealthPlex - Franconia/SpringfieldInova Imaging Center – Fair OaksInova Imaging Center - GainesvilleInova Imaging Center – LortonInova Imaging Center - Mark Center (Alexandria)Inova Loudoun Imaging Center - LeesburgFairfax MRI CenterInova PET/CT Imaging Center – FairfaxThe Fairfax MRI Center at RestonInova Emergency Care Center - FairfaxInova Emergency Care Center - RestonInova Emergency Care Center - Reston/Herndon Comments By submitting this form, you are confirming that you would like to receive health and wellness information from Inova. You can unsubscribe if you find it is not meeting your needs. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
