Request a Callback to Schedule an Outpatient Appointment

Scheduling a medical test or procedure is easy.

Complete the form below
Fax your doctor's prescription to our Centralized Scheduling Department at 954-985-3034
Our staff will contact you no later than one business day after receiving your information

If you are interested in a price quote for a specific test or procedure, call Centralized Scheduling at 954-276-5500.

Patient Information

Full Name Maiden Name Date of Birth Gender Female Male Marital Status Last 4 Digits of Social Security Number

Contact Information

Contact Name (if different) Contact Relationship Street Address City State Postal Code Phone Email Preferred Callback Time

Medical Information

Exam/Procedure Diagnosis Ordering Physician Primary Physician Insurance Company Insurance Authorization/Referral Number

Appointment Preference

Preferred Location(s) Memorial Regional Hospital Memorial Regional Hospital South Joe DiMaggio Children's Hospital Joe DiMaggio Children's Hospital U18 Coral Springs Memorial Hospital West Memorial Hospital Miramar Memorial Hospital Pembroke Preferred Day(s) Monday Tuesday Wednesday Thursday Friday Saturday (limited testing) Sunday (limited testing) Preferred Time(s) Early Morning (6AM - 9AM) Morning (9AM - 12PM) Early Afternoon (12PM - 6PM) Afternoon (3PM - 6PM) Evening (6PM - 9PM)

A doctor's prescription is required for all tests and procedures.

Some insurance companies require an authorization for scheduled procedures. Memorial cannot schedule an MRI or rehabilitation service (PT/OT/ST) without a prior authorization.

Call Us

Contact our Centralized Scheduling Department to get a price quote or schedule an appointment.

954-276-5500

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You Have a Right to Know About Prices

We want to give you the information you need to make important healthcare decisions, including the costs of our services.

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Memorial Named One of "Florida's Best Companies to Work For"

Memorial has been named to Florida Trend magazine's 2015 list of "Florida's Best Companies to Work For." It's the 7th consecutive year that we have ranked on Florida's Trend's list.

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