Scheduling Phone Numbers

Main Number: 541-344-9500

Fax Number: 541-344-9510

Order by Fax

To place an order by Fax, please download our Order Request Form. Please fax PATIENT DEMOGRAPHICS and/or ORDER to:

FAX Number: 541-344-9510

View Results

Imaging results from exams may be viewed via our Carestream PACS server*. Click here to log in.

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WVI Online Scheduling Request

Required Fields are labeld in RED TYPE.

Please fill out the form below to schedule a patient appointment with WVI:

General Information

WVI Pin Number*:	* To obtain a WVI PIN, please contact us at our Main Number. A PIN is required to submit an Online Scheduling Request and acts as your electronic signature.
Completed by:
Insurance Provider:		Policy #:
Requested Appointment Date/Time:	MM/DD/YYYY	Group #:
Pre-Auth Needed?	Yes     No	Referral Required?	Yes     No
Pre-Auth Obtained?	Yes     No	Referral #:
Pre-Auth #:		Ref./PA Expiration Date:	MM/DD/YYYY
Effective Date:	MM/DD/YYYY

Patient Information

Patient Name:		Patient DOB:	MM/DD/YYYY
Phone #:		Other Phone #:
Street Address:		City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming	Zip:
Ref. Physician:		Physician's Ph. #:
Addit. Reports To:		Next Follow-up Dr. Appointment:	MM/DD/YYYY

General Exam Information (all exams)

Exam(s) Requested:		CT MRI CT Discogram CT Myelogram
IV Contrast?		Yes     No     At Radiologist's Discretion
Examination/Area(s) of Special Interest:
ICD-9 / Signs & Symptoms / Clinical Indications:
Previous Exams:		MRI Other CT
Previous Related Surgery:		Yes     No
Pregnant?:		Yes     No
Patient's Height:	(please specify in. or cm.)	Patient's Weight:	(please specify lbs. or kg.)

Special IV Contrast Information:

If you chose "Yes" or "At Radiologist's Discretion" under the question "IV Contrast?" please fill in the following information:
Hx Kidney/Liver Disease?		Yes     No
Hx Diabetes?		Yes     No
Hx Iodine Allergy?		Yes     No
Recent Labs?		Yes     No

Recent Lab Information:

If you chose "Yes" under the question "Recent Labs?" please fill in the following information:
Bun:
Creatinine:
Date of Labs:		MM/DD/YYYY Please fax copy of Labs.