Botsford Hospital
28050 Grand River Ave.
Farmington Hills, MI 48336-5919
(248) 471-8000
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Imaging Services

Request an Appointment

Use this form for non-urgent appointments only.
For urgent appointments within 48 hours, please contact us by phone at (248) 471-8100.
An asterisk (*) indicates required information.

After you submit this form, someone will contact you within 48 hours during normal business hours, Monday through Friday, 9:00 a.m. to 5:00 p.m., except holidays. If you do not hear from us within that timeframe please contact us by phone at (248) 471-8100.

PATIENT INFORMATION
First Name*:
Last Name*:
Date of Birth*:
Primary Phone*:
Alternate Phone:
Email Address*:
   
Physician Name:
Physician Phone:
   
APPOINTMENT INFORMATION
Procedure(s) Needed: Mammography
CT Scan
Bone Density
MRI
X-Ray
Stress Test
Ultrasound
Nuclear Medicine
EEG
Preferred Day of Appointment: Mon. Tue. Wed. Thu. Fri. Sat. Sun.
Preferred Time of Appointment: Morning Afternoon Evening
Best Phone Number to Use:
Best Time to Call: 8-10am 10am-12noon 12noon-2pm 2-4pm 4-6pm
   
INSURANCE INFORMATION
Primary Insurance:
Insurance ID or Policy Number:
Group Number:
Name of Insured (if different from patient):
Comments/Questions:
How did you hear about us?
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Enter the text as it is shown in the above box:
   
 
   

Save yourself time by pre-registering before your procedure or exam.
Call (866) 773-2785.

Who may pre-register?

Any patient may pre-register who is having an outpatient, elective procedure or exam. These include surgical procedures, radiology exams, stress tests, bone density exams or EEGs.

Why would I choose to pre-register?

Pre-registration shortens the length of the on-site admissions process and provides information of out-of-pocket costs you may owe at the time of the exam. When pre-registering, Botsford may offer you a prompt payment discount for any out-of-pocket costs.

How soon may I pre-register before my exam date?

You may pre-register any time in advance of your test, preferably as soon as possible. Pre-registration allows hospital staff time to update information in our computer system, verify insurance coverage, handle special requests and obtain an authorization from the doctor who prescribed the exam.

What do I do if some of my information has changed since I pre-registered?

You can call the Pre-Arrival line to give them your changes, or when you arrive for your exam, let your registration representative know about these changes.

What should I plan for when calling or pre-registering?

We will ask for information including your address, telephone number, insurance carrier, emergency contact, primary care doctor and employer, if applicable.

For questions about pre-registration, please contact the Pre-Arrival Department at Botsford Hospital at (866) 773-2785.