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Appointment Request

Before requesting an appointment - please verify (check off) the following:
I am under 320 pounds.
There is no chance of pregnancy and I am not trying to get pregnant.
I have not had a bypass surgery or stent placement.
I know the scan is from brain to pelvis and does NOT scan the arms or legs.
I have not been treated for cancer in the last year. If yes, we will not be able to give further or more detailed information regarding the cancer. However, we can still screen heart, lungs etc…..
I am over the age of 30. If not, we prefer not to scan unless we have a referral from a physician.
You can e-mail Virtual PhysicalTM directly at Info@VirtualPhysical.com.

If you prefer, you can call us at 410-484-5128
or toll free at 1-866-V-PHYSICAL (1-866-874-9742)

Patient Name: 
Email Address: 
Address:  (optional)
City, State, Zip: (optional)
Home Phone:
Work Phone (optional)
Type of scan:  
Date of Requested Appointment:  
/ (month/day)
Time of Requested Appointment:  
Comments:   

   

Virtual Physical gladly accepts the following forms of payment.


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