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Submit your Referral

Please complete the form below. If you have the order for the procedure please fax it to 855-877-9595. At the very least we need the claimants: Name, Date of Birth, Address, Phone#, Date of Injury, Claim#, Referring Physician Name & Phone#, Procedure being ordered, Adjuster Name and Email.

 

 

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Referral Form

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Send us your referral!

P: 855-877-9292 Option 1

F: 855-877-9595

E: assignment@sl-image.com

W: Click Here

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