X-Ray Referral — Lotus Family Chiro

Patient X-ray Referral

Need patient X-rays? Please fill out the referral information below and we will contact your patient shortly to schedule X-rays!

Lotus Family Chiropractic provides the service of taking digital X-rays. We do not offer any diagnostic interpretation of the X-rays and will ONLY read the images for technical aspects. Diagnostic interpretation will be the responsibility of the referring provider, unless a DACBR report has been requested as a second opinion.

Patient Name

First Name

Last Name

Phone

(###)

###

####

Views Requested

Cervical X-rays AP/Lat/APOM ........$95

Cervical X-rays Flex/Ext.....................$75

Thoracic X-rays AP/Lat .................... $95

Lumbar X-rays AP/Lat ...................... $95

Pelvis X-rays AP/Lat .......................... $95

Full Spine AP/Lat ............................. $205

Other (add in message)

Referring DC

DACBR report?

Message