Patient Portal Access Request

Capitol Imaging Services (CIS) is happy to assist you with setting up your account for our patient portal. Through the portal, you can securely obtain access records for your screening and diagnostic exams performed at a Capitol Imaging Services facility.

Once we receive your request, our I.T. department will begin the work to create your account. Once completed, you will receive an email with instructions on how to begin logging into the portal.

Fields marked with an asterisk are required and must be filled in.

Name*
First Last
Email*
Address
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Secondary Phone
Date of Birth*
Month
Day
Year
Last 4 Digits of Your Social Security Number*
Other information I would like to receive, or specific questions I have:
Name
This field is for validation purposes and should be left unchanged.