Order Diagnostic Services

Patient Information

Patient First Name Please enter patient's first name

Patient Last Name Please enter patient's last name

Date of Birth Please enter date of birth

Gender Please select gender

Primary Phone Number Please enter a valid 10-digit phone number

Secondary Phone Number Please enter a valid 10-digit phone number

Email Address Please enter a valid email address

Address Line 1 Please enter address line 1

Address Line 2

City Please enter city

State Please select a state

ZIP Code Please enter a valid 5-digit ZIP code

Is Patient Covered by Hospice?

Attach Patient Demographics

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Insurance Name Please enter insurance name

Insurance ID / Member Number Please enter insurance member ID

Attach Insurance Card (File Upload)

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First Name Please enter provider's first name

Last Name Please enter provider's last name

NPI Number Please enter NPI number

Facility Name/Practice Name Please enter facility/Practice name

Facility Address/Practice Address Please enter facility/Practice Address

Phone Number Please enter a valid 10-digit phone number

Fax Number Please enter a valid 10-digit fax number

Attach Physician Order

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X-Ray Examination

Symptom / ICD 10 Please select Symptom / ICD 10 or enter Other Symptom / ICD 10

Other Symptom / ICD 10 Please select Symptom / ICD 10 or enter Other Symptom / ICD 10

Ultrasound / Doppler / Echocardiogram

Symptom / ICD 10 Please enter Symptom / ICD 10 or Other Symptom / ICD 10

Other Symptom / ICD 10 Please enter Symptom / ICD 10 or Other Symptom / ICD 10

Diagnosis Please enter diagnosis

Comments / Special Instructions

Reason for Home Visit Please explain the reason for home visit

By clicking on schedule, the Physician is authorizing Reliance Mobile Diagnostics for a home visit.

Online Ordering is only for convenience purpose. Please fax signed Physician Order to 866-871-0838.

Your request has been received. Our team will contact you shortly to coordinate the appointment.