All of our radiologic technologists are registered in multiple modalities by the American Registry of Radiologic Technologists.

Clermont Radiology Imaging Center
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Clermont Radiology, LLC
Ph: 352.241.6100 • Fx: 352.241.6101
871 Oakley Seaver Drive, Clermont, Florida 34711
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Clermont Radiology
Exam Film/CD Image Request
To request an exam image online, please fill-out the form to the right.

You can also fax us your request using the pdf fax form on the left.
* Note, to request multiple exams use the pdf Fax form.
Exam Film/CD Image Request
Film/CD Image Request ~ Fax form
Print form and fax to 352.241.6101
Download Image Request Fax Form

    Clermont Radiology
    Film/CD Image Request ~ Online Form

    Today's Date *
    Physicians Name *
    Physicians Phone *
    Physicians Email
    EXAM REQUESTED
    Patient Name *
    Date of Birth *
    MRN# *
    Exam Requested *
    Images Needed By *
    Requesting *

    Requesting *

     
    * Only required for Mail delivery *
    Office Delivery Location
    Location Name *
    Street Address *
    City *
    State *
    Zip code *
     
    Special Instructions or Comments

    characters left
    Requested By *
    ( Your Name )

    Clermont Radiology
Clermont Radiology
Clermont Radiology LLC • 352.241.6100 • 871 Oakley Seaver Drive, Clermont, Florida 34711
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