Schedule An Appointment with Drew Medical
Welcome to Drew Medical Online Scheduling.  Please fill out the form below and press Submit.  Our scheduling center will process your request immediately.  

If you have any questions please contact the Scheduling Center at: (407) 788-2888. Fields marked with * are required.
Requesting Physician First Name:
*Requesting Physician Last Name:
Name and Phone of person filling out this form in the event we need more information
Office Email
Office Phone
*Patient First Name:
*Patient Last Name
MRN (if available)
*Patient Date of Birth (MM/DD/YYYY)
Patient Weight lbs.
*Patient Gender
Date of Last Menstrual Period (leave blank if not applicable)
Does patient have breast implants? (leave 'No' if not applicable)
Weeks Pregnant (leave blank if not applicable)
*Patient Home Phone
Alternate Phone
Requested Exam(s):
You may request more than one. Please specify:
With contrast
With and without contrast
Without contrast
Reason for Exams - Symptoms - ICD-9 Code
CC result to:
Please indicate if patient has any of the following by check off the box next to the description
Diabetes
One Kidney or Kidney Disease
Iodine or Shellfish Allergy
Aneurysm clip
Stent
History of Renal Insufficiency
History of Neck or Back Surgery
Pacemaker
Metal Rods
None of These
For patients over 70, diabetes, or patients with history of renal disease or problems, we require serum Creatinine within the last 14 days for exams done with IV contrast. Please enter the creatinine level and date of lab, if available. If not, please order ASAP.
Film to Patient
Wet Read?
Wet Read Notification Method
Wet Read Phone or Fax
Insurance Company
Pre-Authorization Number
Secondary Insurance
Preferred Location

Preferred Appointment Time :
Preferred Appointment Date:

      

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