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First Name                                           Last Name


Company                                              Email


Home Telephone #                                 Work Telephone #


Mobile Telephone #



Prefered Appointment Time:                     A.M.             P.M.

Preferred Method of Contact:                    E-Mail           Phone

Best Time to Contact You:                       A.M.             P.M.

Prefer First Available Appointment:           Yes               Does Not Matter

Type Of Scan:














                                   Requested Appointment Information

Appointments
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Please give all your correct information above. Below try to supply us with 1 or 2 different days and times for the appointment and we should be able to accomidate your request. We will contact you within 24 Hours of your request to confirm your appointment. If you have any questions about your appointment please fell free to call 1-888-Doralmr
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Tel: 305-471-4581     Fax: 305-471-4593  1-800-DORALMR
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H.I.P.A.A.
(Health Information Portability & Accountability Act)
          
A.H.C.A
(American Health Care Association)

C.M.S.
(Centers For Medicare & Medicaid Services)

A.C.R.
(American College Of Radiology)

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Doral Medical Imaging,Inc.