CSHS Department of Imaging CD/Film/Image Copy Request

  • Unless specified otherwise, only the most recent study will be provided.
  • Images should be requested at least 48 hours prior to pick-up.
  • We will be happy to release records to a patient's family member as long as the patient sends a signed document, giving a family member consent to do so.

Note: * indicate required fields.

Contact Information
  •  -   - 
  • (you will receive an encrypted e-mail copy of the request)
Requested Exam(s)*
Patient Name Date of Birth Medical # Requested Exam(s) Date of Exam*

*Unless specified otherwise, only the most recent study will be provided.

Additional Comments
Needed By (mm/dd/yyyy)*
  •  /   / 
Purpose for Request*
CD or Film*
Delivery Method*

  • (within a 5 mile radius)

  • S. Mark Taper Imaging Center
    8705 Gracie Allen Drive
    (corner of San Vicente)
    Room M335

By clicking the Submit button below you will be sending your request(s) to ImagingFilmRequests@cshs.org.

Please review your information before submitting this request.
If you have supplied an email address, a copy of the request will also be sent to your mailbox.

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