Request An Appointment | Consulting Radiologists

Where would you like to make an appointment?*

CRL Imaging Plymouth, Plymouth, 15700 37th Ave N
CRL Imaging Southdale/Women’s Imaging, Edina, 6525 France Ave S
LifeScan Minnesota, Edina, 6545 France Ave S

CRL Imaging Plymouth

*Please make sure your primary care provider submits an order for your scan to CRL Imaging Plymouth.
For questions please call: (763) 509-4720

First Name*

Last Name*

Date of Birth*

Primary Care Doctor/Provider*

Home Phone*

Cell Phone

Email*

Home Address*

Street Address Address Line 2 City State ZIP Code

Please indicate the service(s) needed below*

*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?

Yes
No

Do you have a history of breast cancer or radiation to the chest wall (i.e. Hodgkin's Lymphoma)

Yes
No

Are you BRCA Positive?

Yes
No
I'm Not Sure

Have you had a normal or benign mammogram in the last 12 months?

Yes
No

Are you considered high risk (greater than 20% lifetime risk) of getting breast cancer?

Yes
No
I'm Not Sure

Do 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 exam
No

Due 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 Available
Specific 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 Sunday

1st Choice Date*

2nd Choice Date*

3rd Choice Date*

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?

No
Yes

Can we leave a detailed voicemail on your cell phone?

No
Yes

How did you hear about us?*

Friend
Star Tribune
Edina Magazine
Minnesota Monthly
Other - Please Specify

Heard About Us: Other

Terms & 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 Imaging

First Name*

Last Name*

Date of Birth*

Primary Care Doctor/Provider*

Home Phone*

Cell Phone

Email*

Home Address*

Street Address Address Line 2 City State ZIP Code

Please indicate the service(s) needed below*

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 35
35 or Over

Have you had a mammogram in the last 12 months?*

No
Yes

Please 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 needs

Are you pregnant or may be pregnant?*

No
Yes

Have you nursed in the past 3 months?*

No
Yes

If 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?*

Annual
New Concerns

Briefly 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?*

Yes
No

Do you have a history of breast cancer or radiation to the chest wall (i.e. Hodgkin's Lymphoma)*

Yes
No

Are you BRCA Positive?*

Yes
No
I'm Not Sure

Have you had a normal or benign mammogram in the last 12 months?*

Yes
No

Are you considered high risk (greater than 20% lifetime risk) of getting breast cancer?*

Yes
No
I'm Not Sure

Do 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 exam
No

Due 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 Available
Specific 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 Sunday

1st Choice Date*

2nd Choice Date*

3rd Choice Date*

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?

No
Yes

Can we leave a detailed voicemail on your cell phone?

No
Yes

Are 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: Other

Terms & 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 Minnesota

We’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

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