Thank you for choosing SRC for your medical imaging. This pre-registration form is designed to save you time on the day of your exam.  It covers basic information about you and provides us with the names of the party or parties responsible for payment. It also allows us to prepare your medical record in advance of your arrival so that we can proceed quickly to your exam.  Please complete and submit the form at least one day prior to your exam.

We will still need to copy your insurance card(s) on the day of the exam as well as ask you for your Doctor's written order or referral for verification purposes. 

If you have access to a fax, you can fax a copy of your insurance card(s) and the Doctors order to the attention of "Pre-registration" at 503.371.0777. 

Please be sure to alert our staff that you have pre-registered when you come in to assure you receive the benefit of pre-registering.

Download the Pre-Registration Form Here
Forms require free Adobe Reader; Click here to download if necessary

Please complete and submit the form at least one day prior to your exam
Print and fax to 503.371.0777

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