Request an Appointment Quick Links Premier Urgent Care Logo This request form is for X-Ray and CT appointments only. For other services please visit Premier Urgent Care. Request an Appoinment Fields marked with an * are required. First NameMiddle InitialLast NamePhoneEmail What insurance do you have?Preferred Date of Appointment Preferred Time of Appointment:Do you have a physicians order- select yes or no- if no who referred you. Yes No Physician that referred you.Message This iframe contains the logic required to handle Ajax powered Gravity Forms. **PLEASE DO NOT SUBMIT ANY PERSONAL INFORMATION** (Ex. SSN, Date of Birth, Driver License Number, or Insurance Policy Number)
