AHBD Quest Imaging Request Form

Imaging Request Form
You will need a valid ID when you pick up your imaging records. If you need your imaging records sooner than the date available, please call (661) 617-4030.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Images/Exams you're requesting*
Date exam completed*
If you don’t know the date your exam was completed, please select one of these options

Most recentUnknown
Referring Physician*
Will you be taking these images out of town?*

YesNo
Pick up date and time:*
Pick up location*

Quest Imaging - Chester Ave.Quest Imaging - Stockdale Ave.
Please verify that you are human*
By providing your details and clicking "Submit" you agree to:
- Receive communications from Adventist Health through email, SMS, text, or calls by an automated telephone dialing system for the purpose of Adventist Health maintaining its relationship with you and providing you information related to services you may be interested in.
- Adventist Health collecting and disclosing to third parties personal information and communications for the purpose of fulfilling your inquiries or requests for services or information.
Should be Empty: