Cypress Women's Imaging provides this online appointment request service to simplify the scheduling process for patients. This online appointment request form may be used to only request a non urgent appointment. Please note that information submitted on this form may not be secure or confidential. Detailed information regarding your exam and appointment with Cypress Women's Imaging will be discussed with you on the phone at the time your appointment is scheduled.

You may request an appointment online at anytime. Simply fill out the form below and one of our staff will call or email you to schedule your exam. We will call or email you within 1 business day of your request. Please note your appointment is not scheduled until Cypress Women's Imaging has confirmed the receipt of information provided in this form. Response time for appointments requested online is only available Monday-Friday 8AM - 5PM, excluding holidays. To ensure the accuracy and completeness of your scheduled appointment, please have the order from your physician and your insurance card available for reference when we contact you.

If we miss you or if you prefer to call us to schedule an appointment, please dial 316-681-1827.

* = Required fields

Appointment Request Form

*  Patient in possession of order for exam? Yes     No
Please note: We can not perform a diagnostic imaging procedure without a written requisition from your referring physician. Please contact your referring physician's office to obtain the proper requisition.
*  Last Name
*  First Name
*  Date of Birth (ex: 02/01/1967)
*  Contact Phone
    Alternate Phone
    Email
*  How do you prefer we contact you?
*  May we leave a voicemail? Yes     No
*  Referring Physician Name
    Type of exam requested
 
        

Clicking the Request Appointment button will send a message to Cypress Women's Imaging. We will not collect any personally identifiable information about visitors unless it is provided voluntarily. Any information shared by visitors through the Cypress Women's Imaging website is not shared with any other entities. This site contains links to other sites. We are not responsible for their privacy practices or content. Notice of Privacy Practices

You should receive a response to your request within 1 business day. If you do not receive a response within 1 business day, please call our office at 316-681-1827.