Image Order Form
Hours of Operation: 8am - 6pm Monday - Friday
Phone: (617) 726-1798
Fax: (617) 724-0264


  • Note: Signed Release Authorization Forms (1, 2) below are required for ALL Images and Medical Reports released.
    ----(1) Authorization to Release Images - Download pdf
    ----(2) Authorization to Release Medical Report and Images to Third Parties- Download pdf
  • For mailed images/films/reports, please FAX authorization forms to 617-724-0264
  • Please print your confirmation and use the Reference Number when calling for information regarding your order.
  • For Mammogram orders, unless otherwise requested by your physician, we will send images from two previous exams in addition to the films from your most recent visit.
View Previous Order
Fields marked * are required.
PATIENT INFORMATION:

Name: *
Address: *
City: *
State: *
Zip: *
Day Phone: * (enter numbers only - 18005551234)
DOB: - - * (MM-DD-YYYY)
MGH Blue Card# MRN: *

Please select only (1) one OPTION from below:

OPTION 1
OPTION 2
No Charge - CD or Digital Copies of Films - Sent directly to *HCP.
No return necessary. CD / Copies of Films cannot be mailed directly to patient.
(Unless otherwise requested, CD will be sent.)
OPTION 3
Purchase - CD or Digital Copies of Films - Mailed directly to
Patient. No return necessary. Credit Card necessary.
(Unless otherwise requested, CD will be sent.)
* Health Care Provider

If Option 3 Selected - Please Choose one of the Following:
CD/ROM
Purchase - No return necessary
FILM COPY
Purchase - No return necessary

PLEASE SPECIFY DATE(S) AND TYPE(S) OF STUDIES TO BE LOANED OR PURCHASED:

* Date of Exam: (MM/DD/YYYY)
Please be as specific with dates as possible. If you cannot provide exact dates, month and year will be accepted. Contact the Image Service Center if you are unable to provide any specifics.
Type of Study / Films:
 
- -  
- -  
- -  
- -  
- -  
- -  
- -  
- -  
- -  
- -  

 

Film Subtotal
-------
$0.00
SHIPPING ADDRESS: (Choose one of the following)

Same address as patient info
Other
Name:
Address 1:
Address 2:
City:
State:
Zip:
Pick up at Mass General Hospital Boston, MA

SHIPPING METHOD: (Choose one of the following)

  First Class - 15-20 Day Delivery (no charge)   UPS with credit card
  FedEx with credit card