PATIENT REGISTRATION ONLY FILL OUT THE FORM BELOW IF YOU NEED A REFERRAL OR DOCTOR'S ORDER FOR AN X-RAY OR MRI. IF YOU ALREADY HAVE A REFERRAL/DOCTOR'S ORDER FOR IMAGING, PLEASE SEE THE 'HOW IT WORKS' SECTION. FastXray Screening Form First*Middle Initial*Last*Date of Birth* Gender*MaleFemaleOtherAddressStreet Address*Street Address 2City*State*Zip*Phone - Cell*Phone - HomeRequired for Portal AccessEmail* Password*Confirm*Secret Question Hint*What street did you grow up on?What is your mother's maiden name?What is the name of your first school?What is your pet's name?What is your father's middle name?What is your school's mascot?Secret Question Answer*Location of Pain or Injury (Check all that apply)* finger hand wrist forearm elbow upper arm shoulder collar bone neck back pelvis hip thigh knee lower leg ankle foot toe Which Side Right Left Brief description of pain or injury*Be sure to include the what/where/when/why and how description(s) of your pain or injury.Is there an open wound?*NoYesAn open wound would be a deep cut with or without bleeding over the bone or joint, a bone sticking out through the skin, or any exposed tissues below the skin levelIs there a deformity of the extremity?*NoYesA deformity is when the area of the body does not appear normal. It may appear unusually angulated, or bent. Is there numbness or tingling?*NoYesIs this a high speed injury or a fall from a height?*NoYesHigh speed injuries, such as motor vehicle accidents, as well as falls from a height above ground level, are more likely to produce significant soft tissue swelling, which even if there is not a fracture can itself be a significant injury that requires more emergent medical attentionIs the joint or extremity red or hot?*NoYesA red/hot area over a joint or extremity, with or without swelling, can indicate infection.Is there a penetrating trauma, such as a stab or gunshot wound?*NoYesAre there additional injuries such as abdominal or head pain or trauma?*NoYesDo you have signs of generalized illness such as fever, chills, nausea, vomiting or diarrhea?*NoYesDo you agree to the Terms of Service?* Yes Unfortunately FastXray can not care for your level of injury, we recommend you go immediately to a higher level of medical care for Urgent/Emergent evaluation.Your information has been submitted to our reviewer. Shortly, you will receive further instructions. EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.