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Radiology Record Request
Submit a request with the online form below and records will be prepared for pickup.
Please note:
The images and report can be electronically forwarded to a physician office if listed as a transfer facility below. It is not necessary to come to LMH to pick up records if this option is selected.
First name:
Last name:
Date of birth:
Calendar
Phone number:
(
)
-
Second part
Third part
Exam requested:
X-Ray
CT
MRI
Mammogram
Ultrasound
Nuclear Medicine
PET
Date of exam:
Calendar
Format:
Radiologist written report only
Images on CD, including report
Electronic transfer of images/report to another office (choose the office)
Security code:
Enter security code:
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1320 West Main Street, Newark OH 43055 • Telephone: (220) 564-4000