Scheduling Online

C2C schedules procedures at a nearby location within 24-48 hours from the original call.  Same-day scheduling is always available upon request.  Patients can either call toll-free (800) 730-9263 to schedule a procedure or use the online scheduling from below.

C2C schedules the patient’s follow-up appointment with the referring physician.

Schedule An Appointment Online

Please fill out the scheduling form as complete as possible. Someone from our staff will contact you within 24 hours. Thank you for choosing Coast2Coast!

    Online referrals
    All fields marked ( * ) are required

    Patient Information

    * Last Name:

    * First Name:



    Social Security:


    Date of Birth:





    Zip Code:

    * Patient Phone:


    Employer Name:

    Employer Phone:


    Insurer's Information

    * Insurer:


    * Adjuster's Name:

    Case Management Nurse:

    * Adjuster's Phone:


    Nurse's Phone:


    Adjuster's Fax:


    Nurse's Fax:


    * Date of Injury:


    * Claim Number:

    * E-Mail:

    Physician Information

    * Referring Doctor:

    * Doctor Phone:


    Doctor Fax:



    Doctor Specialty:

    Procedure Information

    * Test Performed

    * Body Part

    Diagnosis / R/O

    Test Performed

    Body Part

    Diagnosis / R/O

    Test Performed

    Body Part

    Diagnosis / R/O

    Submitter's Information

    * Submitter Role:
    Enter Role if other above:

    (choose one) I am the:

    * Submitter Email:

    Attach files up to 3MB each

    File 1:

    File 2:

    File 3:

    File 4:

    File 5: