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Patient Forms

To expedite your appointment wait time, please print and fill out these patient forms and bring with you at the time of your appointment.

New Patient Forms

[English] [Spanish]

Returning Patient Forms

[English]  [Spanish]

MRI Patient Forms

MRI Patients also need to complete 'Returning' or 'New Patient' forms.

[English]  [Spanish]

MRI with IV Sedation Patient Forms

[English]  [Spanish]

Release of Medical Records

(The intended use of this form is to release your Radiology Regional records to another entity.)



Request Images from other facilities

In order for Radiology Regional Center to obtain your records from other facilities, please fill out this request form and submit to previous provider.

Request for Medical Records


Request for Breast Imaging Medical Records


Other Documents

Notice of Privacy Practices (for your records only)

[English]  OR  [Spanish]



Contact Us (239) 936-2316

* All Copay, Coinsurance, and Deductible fees are Due at time of Service.

We Accept Cash, Check and Credit Cards:

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Radiology Regional Center - serving the diagnostic needs of Ft. Myers, Cape Coral, Lehigh, Estero, Bonita Springs, and Naples, Florida with X-Ray, MRI, CT, PET, Ultrasound, Digital Mammography, Mobile Mammography, DEXA, Breast Biopsy, Nuclear Medicine & Nuclear Cardiology, Vascular Screenings, Interventional Radiology, Varicose and Spider Vein Treatments, Aesthetic Treatments, and CT Health Screenings.