Imaging Order Forms

Thank you for choosing Wesley for your patient's imaging exams. We have streamlined our ordering process and invite you to print order forms to assist in providing accurate patient information.

Please select the proper PDF form, print it, and complete it. Fax the form, along with the patient's current medication list, recent lab values (if done within 30 days), pertinent medical reports and other helpful information.  If you choose to hand-write the information, please use a bold black pen.

Please note the patient name at the top of each sheet.

Fax to only one number, the Wesley Fax Server: 316-962-7827.

We look forward to working with you to enhance the patient experience and ensure the best possible outcomes.

Forms:

Diagnostic Imaging

Nuclear Medicine Imaging

Outpatient Breast Imaging

Outpatient CT Imaging

Outpatient MRI Imaging

Ultrasound Imaging

Vascular/Interventional Imaging

These forms require Adobe Reader. If you do not have Adobe Reader, you may download it free here:
Get Acrobat Reader (this link opens a new browser tab or window).