Virginia Mason Franciscan Health Image Transfer Request Form

Your Facility Name *

Contact Person *

Contact Phone *

Referring Provider *

Patient Last Name *

Patient First Name *

Patient Middle Initial *

Patient Date of Birth *

Patient Date of Birth (mm/dd/yyyy) is required

I want to

Request Images from VMFH Send images to VMFH

Destination Provider or Specialty Clinic

Priority (7 days per week 7am-5:30pm)

Routine (studies will be transferred within 12 hours) Urgent (studies will be transferred within 1 hour)

#	Exam Description * e.g. CT Head w/Con.	Exam Date * MM/DD/YYYY	Modality * Pick from list	# of series in exam/image count e.g. 3/68
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Special Instructions

Authentication *

* Required