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OUR MISSION: To foster healing and health for the people and communities we serve.

Neurosurgeon Consultation Request

Please fill out the following form and a scheduler will call you back.  

All medical imaging exams, with the exception of routine mammograms, require a written and signed order by the physician.  

Our Fax number is 303.689.4187

* Indicates required information
First Name * 
Last Name * 
Date of Birth (xx-xx-xxxx) * 
Patient's Phone Number * 
Email Address 
Signs/Symptoms * 
Patient's Physician Name * 
Patient's Physician Phone Number * 
Insurance Name * 
Exam Type * 
Best Day/Time for the Appointment * 
Best time for Scheduler to call patient/office to arrange appointment * 
Questions or Concerns 
Authentication * 

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┬ę 2014 Exempla Healthcare | 2420 West 26th Avenue | Denver, CO 80211 | 1-866-EXEMPLA
For patient billing inquires please contact Revenue Service Center at 1-866-665-2636 | 500 Eldorado Blvd. Suite 6300, Broomfield, Colorado 80021