Request An Appointment Where would you like to make an appointment?*CRL Imaging Southdale/Women’s Imaging, Edina, 6525 France Ave SLifeScan Minnesota, Edina, 6545 France Ave SCRL Imaging Plymouth*Please make sure your primary care provider submits an order for your scan to CRL Imaging Plymouth. For questions please call: (763) 509-4720First Name*Last Name*Date of Birth* Date Format: MM slash DD slash YYYY Primary Care Doctor/Provider*Home Phone*Cell PhoneEmail* Home Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Please indicate the service(s) needed below* MRI Breast MRI Pain Management Injections General X-Ray Ultrasound Thyroid Biopsy & Aspiration MR Enterography Paracentesis Lung Cancer Screening *Eligibility determined by clinical history. Please note this is an out of pocket expense at a flat rate. Please call for a quote. You must arrive 15-30 minutes prior to the exam to fill out paperwork.Do you have anything metal or foreign in your body, accidentally or surgically?YesNoDo you have a history of breast cancer or radiation to the chest wall (i.e. Hodgkin's Lymphoma)YesNoAre you BRCA Positive?YesNoI'm Not SureHave you had a normal or benign mammogram in the last 12 months?YesNoAre you considered high risk (greater than 20% lifetime risk) of getting breast cancer?YesNoI'm Not SureDo you suffer from claustrophobia?*If you are claustrophobic, we recommend to consult your physician for a prescription to be taken prior to your exam; or notify our imaging team by selecting the appropriate box below.Yes - I will provide my own medication (preferred)Yes - CRL to provide medication prior to examNoDue to your answer above, abbreviated breast MRI may not be the right exam for you. Please call us after submitting this form at 763-509-4720 and we will assist you with your specific imaging needs.Would you prefer your appointment be the first available or on a specific date?First AvailableSpecific Date (to be indicated below)Please list in order of priority your top three choices for appointment dates: Hours at this facility are: Monday - Friday: 7:30am - 4:30pm Closed Saturday and Sunday1st Choice Date* Date Format: MM slash DD slash YYYY 2nd Choice Date* Date Format: MM slash DD slash YYYY 3rd Choice Date* Date Format: MM slash DD slash YYYY Please indicate below what time of day works best for you:* Morning (8:00am - 11:00am) Midday (11:00am - 2:00pm) Afternoon (2:00pm - 4:00pm) Other (Please Specify) Specific Time of Day*Please indicate below the best way our representatives can get in touch with you:* Home Phone Cell Phone Email Doesn't Matter Can we leave a detailed voicemail on your home phone?NoYesCan we leave a detailed voicemail on your cell phone?NoYesHow did you hear about us?* Friend Star Tribune Edina Magazine Minnesota Monthly Facebook Twitter Other - Please specify Heard About Us: OtherTerms & Conditions* By checking this box you agree to have submitted nonfraudulent information. * CRL is not responsible for loss of information submitted through this online secure form CRL Imaging Southdale / Women's ImagingFirst Name*Last Name*Date of Birth* Date Format: MM slash DD slash YYYY Primary Care Doctor/Provider*Home Phone*Cell PhoneEmail* Home Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Please indicate the service(s) needed below* Mammogram Upright Stereotactic Breast Biopsy Ultrasound-Guided Breast Biopsy Breast Ultrasound Ultrasound-Guided Cyst Aspiration X-Ray Ultrasound Fine Needle Aspiration (FNA) Thyroid DXA Bone Density Which technology do you prefer?* 2D (Digital) Mammography 3D Mammography (Tomosynthesis) Would like to learn more Please note: Some insurance providers do not cover 3D Mammography. Please check with your provider prior to your appointment.What is your age?*Under 3535 or OverHave you had a mammogram in the last 12 months?*NoYesPlease select if you have any of the following:* Implants Any Breast Surgery Any Special Needs (i.e. Hearing/Visually Impaired) Need an Interpreter None of These Please specify your breast surgery(s)Please specify your special needsAre you pregnant or may be pregnant?*NoYesHave you nursed in the past 3 months?*NoYesIf you have nursed in the past 3 months, please schedule your Mammogram 12 weeks after the date you stopped nursing.Is this an annual mammogram or do you have new concerns?*AnnualNew ConcernsBriefly explain your new concerns below:Due to your new concerns, please call us after submitting this form at 952-915-4320 and we will assist you with your specific imaging needs.Eligibility determined by clinical history. *Please note this is an out of pocket expense at a flat rate. Please call for a quote. You must arrive 15-30 minutes prior to the exam to fill out paperwork.Do you have anything metal or foreign in your body, accidentally or surgically?*YesNoDo you have a history of breast cancer or radiation to the chest wall (i.e. Hodgkin's Lymphoma)*YesNoAre you BRCA Positive?*YesNoI'm Not SureHave you had a normal or benign mammogram in the last 12 months?*YesNoAre you considered high risk (greater than 20% lifetime risk) of getting breast cancer?*YesNoI'm Not SureDo you suffer from claustrophobia?*If you are claustrophobic, we recommend to consult your physician for a prescription to be taken prior to your exam; or notify our imaging team by selecting the appropriate box below.Yes - I will provide my own medication (preferred)Yes - CRL/TCMI to provide medication prior to examNoDue to your answer above, abbreviated breast MRI may not be the right exam for you. Please call us after submitting this form at 952-915-4320 and we will assist you with your specific imaging needs.Would you prefer your appointment be the first available or on a specific date?First AvailableSpecific Date (to be indicated below)Please list in order of priority your top three choices for appointment dates: Hours at this facility are: Monday - Friday: 7:30am - 5:00pm Closed Saturday and Sunday1st Choice Date* Date Format: MM slash DD slash YYYY 2nd Choice Date* Date Format: MM slash DD slash YYYY 3rd Choice Date* Date Format: MM slash DD slash YYYY Please indicate below what time of day works best for you:* Morning (7:00am - 12:00pm) Afternoon (12:00pm - 4:00pm) Evening (4pm - Close) Other (please specify) Specific Time of Day*Please indicate below the best way our representatives can get in touch with you:* Home Phone Cell Phone Email Doesn't Matter Can we leave a detailed voicemail on your home phone?NoYesCan we leave a detailed voicemail on your cell phone?NoYesAre you a current CRL patient or a new patient?* I'm a new patient Current patient How did you hear about us?* Friend Star Tribune Edina Magazine Minnesota Monthly Other - Please Specify Heard About Us: OtherTerms & Conditions* By checking this box you agree to have submitted nonfraudulent information. CRL is not responsible for loss of information submitted through this online secure form LifeScan MinnesotaWe’re sorry, LifeScan Minnesota cannot take requests online. Please call to make an appointment Phone: 952-893-1997 Hours: Mon – Fri: 8:00am – 5:00pm I'm not a robotCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
