Email Name First Last Practice Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Office PhoneThe CIS location order form you wish to order:* Advanced Imaging of Lafayette Ascension Open MRI Baton Rouge Imaging Bluebonnet Imaging Center Central Imaging Center Diagnostic Imaging Services Doctors Imaging Heritage Diagnostic Center Homosassa Open MRI Imaging Center of Columbus Imaging Center of Meridian Louisiana PET/CT Imaging of Lake Charles M.R. Imaging Systems Northeast Imaging Northwest Imaging Open Air MRI of CENLA Open MRI of Hammond Open MRI of Mississippi PARS Imaging River Bend Imaging Southern Imaging Specialists Texarkana PET/CT imaging Institute Vestavia Hills Imaging Center Number of Pads: Other Supplies: Pens and Pads Needed: CIS Pens (black ink) CIS 3"x3" Note Pads (25 sheets per pad) Other information I would like to receive or specific questions I have: Δ
