Patient Registration

A Leader In Diagnostic Radiology Throughout SE Missouri

Registration Forms

Prior to your visit to Midwest Imaging Center, please print the appropriate forms packet and fill it out as completely as possible. You should bring it with you to your appointment or FAX to:

Midwest Imaging Center – Farmington
(573) 760-0228 Fax

Midwest Imaging Center – Potosi
(573) 436-7321 Fax

MRI Screening Form (pdf)

Patient Records Release Form (pdf)

Patient Information Form (pdf)

Cancellation Policy

If you need to cancel or reschedule your appointment for any reason, please call our office immediately. We reserve this time for you only. We do not double and triple book appointments because we want to be able to focus on your exam while you are here. Failure to contact our office 24 hours before your exam, with the exception of emergencies, may result in a $25 non-cancellation fee.

Experience the difference and schedule your appointment today