Register For Your Exam

Thank you for choosing Western Imaging for your exam.

This pre-registration form is designed to save you time on the day of your exam. Please complete and submit the form at least one day prior to your exam.

We will still need to copy your insurance card on the day of the exam as well as ask you for your Doctors orders for verification purposes. Please be sure to alert our staff that you have pre-registered when you come in to assure you receive the benefit of pre-registering.

All areas marked (*) are required fields.

PATIENT INFORMATION

Last Name*

First Name*

Work Phone

Primary Phone*

Email Address

Street Address*

City*

State*

Zip*

Gender
Male Female

Date of Birth (MM/DD/YYYY)

Employer Name

Employer Address

City

State

Zip

Referring Physician

Injury Date (MM/DD/YYYY)

Date of Your Exam (MM/DD/YYYY)

Exam Location
Culver City Marina del Rey

RESPONSIBLE PARTY (Name of insured)

Last Name

First Name

Phone

Employer

Street Address

City

State

Zip

PRIMARY INSURANCE

Insurance Company

Phone

Street Address

City

State

Zip

Subscriber/Policy Holder

Relationship to Patient

SECONDARY INSURANCE

Insurance Company

Phone

Street Address

City

State

Zip

Subscriber/Policy Holder

Relationship to Patient

ATTORNEY INFORMATION (IF APPLICABLE)

Attorney's Last Name

Attorney's First Name

Phone

Street Address

City

State

Zip

SUBMIT YOUR INFORMATION

Click below to submit your data and you'll receive confirmation of receipt.
If necessary, we will contact you for additional information.