Get the free Conventional Radiograph Request Form

Division of Oral and Maxillofacial RadiologyCONVENTIONAL RADIOGRAPH REQUEST FORM FOR EXTERNAL REFERRING PRACTITIONERS PATIENT INFORMATION Name:Date of Birth:Gender:Mailing Address: Phone (Cell/Home/Work):

How to fill out conventional radiograph request form

How to fill out conventional radiograph request form

1. Obtain the conventional radiograph request form from the imaging facility or download it online.
2. Fill out the patient's demographic information including name, date of birth, and contact details.
3. Provide the reason for the radiograph request, which includes the specific body part or area to be examined.
4. Indicate any relevant medical history or conditions that may impact the radiograph results.
5. Include the ordering physician's name, contact information, and signature on the form.
6. Submit the completed form to the imaging facility along with any other required documents.

Who needs conventional radiograph request form?

1. Patients who have been referred by their healthcare provider for a conventional radiograph procedure.
2. Healthcare professionals such as physicians, nurses, or radiologic technologists who are ordering the radiograph for diagnostic purposes.

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What is conventional radiograph request form?

A conventional radiograph request form is a document used by healthcare professionals to order imaging studies, specifically X-rays, and to provide essential patient information and clinical indications for the procedure.

Who is required to file conventional radiograph request form?

Healthcare providers, such as physicians and radiologists, are required to file conventional radiograph request forms when they deem X-ray imaging necessary for diagnosis or treatment.

How to fill out conventional radiograph request form?

To fill out a conventional radiograph request form, the healthcare provider needs to include patient details, clinical history, specific body parts to be imaged, the reason for the request, and any pertinent prior imaging information.

What is the purpose of conventional radiograph request form?

The purpose of the conventional radiograph request form is to ensure proper documentation and communication between healthcare providers and radiology departments, guiding the imaging process and ensuring appropriate patient care.

What information must be reported on conventional radiograph request form?

The information that must be reported includes the patient's name, date of birth, unique identification number, clinical indications for the radiograph, specific examination requested, and the referring physician's details.