Film Request Form – Naugatuck Valley Radiology

Film Request Form

By agreeing to the terms of our secure forms, you will enter a secure area of our web site. Naugatuck Valley Radiology will not be held responsible in the event your electronic message is not transmitted due to technical problems related to this site or to the hosting server. All personal identifying information is encrypted and your message will not be internally or externally forwarded to other parties. The information will solely be used by Naugatuck Valley Radiology. If you do not accept the terms of this disclaimer, you will not be able to process your request on-line.

We will confirm your request by phone or by email. On-line requests will be followed up within one business day of request receipt, Monday through Friday, 8:00 a.m. and 5:00 p.m. If you do not receive a response from us within 48 hours, or if you have any questions, please contact our office by phone at (203) 574-1311.

Important Items to Note

Allow 2-3 days advance notice of desired film pick up.
When picking up your films or reports, you will need to present photo identification. If someone other than the patient is picking up the films, a signed, written authorization from the patient is required.
Mammogram films are loaned to you and should be returned as soon as possible.

An asterisk (*) indicates required information
Patient Information
First Name*
Middle Initial
Last Name*
Address
City
State
Zip Code
Email
Patient's Date of Birth*
Daytime Phone*
Alternate Phone
Film Request
What specific films are you requesting and approximate date of exam?*
Film Type* To select multiple film types, please hold down the Ctrl key while making your selections.
Pick Up Location*
Other Details - Required
What doctor's office or facility are you taking these to?* (Please indicate your doctor's first and last name.)