Send us your referral in three easy steps

1.

DOWNLOAD

MBS Imaging Referral Paperwork

SKILLED NURSING FACILITY PATIENT

HOME HEALTH PATIENT

Endoscopic

Swallow Study

Modified Barium Swallow Study

MBSS/VFSS

Modified Barium Swallow Study

MBSS/VFSS

COMPLETE referral paperwork

2.

In order to see a patient at a facility or at their home kindly submit the following paperwork to us via fax, email, or send it online.

1. Dysphagia Consult Request Form 

2. Patient Consent Form

3. Face Sheet from chart

4. Physician Order from chart

FAX: 877-495-7208

ONLINE:

Use your phone or tablet device to transmit each referral page to MBS Imaging.

  • Once you add one file, click "add another file" until all documents are uploaded

  • Include your email address

  • Add any special notes

  • Hit "send"

3.

SUBMIT referral paperwork via: 

© 2017 MBS Imaging LLC

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1919 S Highland, Ave, Lombard, IL 60148

Fax: 877-495-7208

Tel: 877-495-7152