Welcome to SimonMed, the largest and most advanced medical imaging provider in the Southwest.

Request Films

Name
SSN
Date of Birth	( mm/dd/yyyy )
Gender	MaleFemale
Reason for Release
Date of Last Appointment (Optional)	( mm/dd/yyyy )
Stat	YesNo
Office Requesting
Person Requesting
Date Needed By	( mm/dd/yyyy )
Format Requested	Printed FilmsCD
Type of Studies to be Released	MRI CT Scan Ultrasound Breast MRI X-Ray Dexa Mammogram Other
Film Receiving Options	DeliveryPickup
Delivery Address
By submitting a request for patient medical records, I certify that I am a health care provider who is treating the patient whose medical records I am requesting. I understand and acknowledge that pursuant to the Health Insurance Portability and Accountability Act, I may be subject to civil and criminal penalties for accessing medical records without proper authorization.
Signature (Click and hold mouse button to sign)	Clear Signature
Submission Date	( mm/dd/yyyy )