Request Images or Reports

Patient Info
Contact Info

(This will only be utilized for confirmation that we have received the online request)


Please Provide the 10 digit primary phone number to contact you during daytime hours. Any additional phone numbers we may use should also be listed.

Phone 1 Type
Phone 2 Type
Phone 3 Type
May we leave a voicemail message if prompted?

Unless you indicate the exact date(s) of service we must contact you to confirm which images you are requesting.

In what format do you need your images or reports?
Please check the location for hours of operation.
Physician Requesting the Images
Just enter the 10 digits of the number without spaces or dashes.
Physician Address
Who will pick up the images?

To assure your privacy, all individuals picking up images will be required to provide a picture ID

If other, please provide the name
I understand Fairfax Radiology will not release my images to anyone other than myself without written authorization from me.