Virginia Mason Image Transfer Request Form

* Indicates required information
Requester Information 
Your Facility Name: * 
Contact Person: * 
Contact Phone: * 
Referring Provider: * 
Patient Information 
Patient Name: *  Last 
First 
Middle Initial 
Patient DOB: *   DD/MM/YYYY
Destination Information 
I want to: 
OR

      Destination Provider or Specialty Clinic:
     
Priority: 
(7 days per week 7am-5:30pm) 
Routine-studies will be transferred within 12 hours 
Urgent-studies will be transferred within 1 hour 
Study Details 
# Exam Description *
e.g. CT Head w/Con. 
Exam Date *
MM/DD/YYYY 
Modality *
Pick from list 
# of series in exam/image count 
e.g. 3/68 
1
2
3
4
5
6
7
8
Special Instructions: