Appointments

Request an appointment

Complete the form below and our scheduling team will contact you within one business day to confirm your appointment.

Call Us Directly

718-489-3610

Confirmation

Within 1 business day

Patient Information

First Name *

Last Name *

Phone Number *

Email Address

Date of Birth

Study Information

Type of Imaging *

Insurance Provider

Referring Provider (if applicable)

Preferred Date

Preferred Time

Additional Information

Notes for Scheduling Team

Do not include detailed medical history or sensitive health information here. Our team will gather clinical details by phone.

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HIPAA Notice: This form collects basic scheduling information only. Do not include detailed medical history or sensitive health information. Our team will contact you to gather clinical details by phone.

I understand that this form collects basic scheduling information only and does not constitute a medical record or guarantee an appointment. I consent to being contacted by Clearview Radiology at the phone number or email provided above to confirm my appointment. I acknowledge that Clearview Radiology handles all patient information in accordance with HIPAA privacy regulations.

By submitting this form, you agree to be contacted by our scheduling team. This form is not a HIPAA-covered communication channel, do not include protected health information.