Physicians’ Portal

MERGE iConnect®

Zero footprint technology allowing access to images and reports anywhere in the world.

Physicians' Requisition Form

Please fill out the following details to submit your requisition online.

 

Locations:

Patient information:




Sex:
 
 

Appointment Necessary:

 

 

 

 

Clinical Information:

Referring Physician Contact Information:

Alternatively, the requisition form may be downloaded for offline completion.

Email completed forms to eriestclair@gmail.com.