PowerShare Image Request Form | Atlantic Medical Imaging

WELCOME TO THE IMAGE/REPORT REQUEST FORM

We are pleased to offer an easy to use tool for online access to your images. The PowerShare™ Network is a quick and convenient solution that gives you secure access to your imaging studies whenever you need them.

Please complete the form below and you will receive an Invitation Email from Atlantic Medical Imaging to join the Nuance® PowerShare™ Network. It will only take a few minutes to setup your account and you will then have the ability to view, copy and share your images with your healthcare providers.

Please allow 24-48 business hours for processing.

First Name*

Middle Initial

Last Name*

Address

Apartment/Suite

City

State

Zip Code

Date of Birth*

Date

Email*

Confirmation Email

Phone*

Area CodePhone Number

Other Number

Area CodePhone Number

May we leave a voicemail if prompted?*

Exam Image(s) Requested*

Clinician's Name*

Date(s) of Service

I Agree