Get the free Imaging Request Form - PET/CT Scans

The Yorkshire Clinic Imaging Center. Scan Request CT MR. Patient name: Radiologist: Date: Yes No. Does your patient have? (please tick): Cardiac pacemaker.

How to fill out imaging request form

How to fill out an imaging request form:

1. Start by obtaining a copy of the imaging request form. This can usually be done by visiting the website of the imaging facility or hospital where you plan to have the imaging done. Some facilities may also provide physical copies of the form at their reception or imaging departments.
2. Carefully read and understand the instructions or guidelines provided on the form. This will help ensure that you provide all the necessary information required for the imaging procedure.
3. Begin filling out the form by entering your personal information, such as your full name, date of birth, and contact details. It's important to provide accurate information to avoid any potential mix-ups or delays in scheduling your imaging procedure.
4. The form may then ask for specific details regarding the type of imaging you require. For example, if you are seeking an X-ray, MRI, or CT scan, you may need to indicate this on the form.
5. Provide further details about the specific area or body part that needs to be imaged. This can include specifying if it's an upper extremity, lower extremity, abdomen, chest, or any other relevant details based on the imaging procedure.
6. If you have any relevant medical conditions or allergies, make sure to mention them on the form. This information is crucial for the imaging professionals to ensure your safety during the procedure.
7. In some cases, you may need to enter the name of your referring physician or healthcare provider who requested the imaging. This allows the facility to send the results to the appropriate healthcare professional for follow-up.
8. Lastly, review the completed form to ensure all the required fields are filled out accurately and completely. Double-check for any spelling errors or missing information.
9. Keep a copy of the filled-out form for your records, and submit the form to the imaging facility as per their instructions. Some facilities may require you to bring the form in person, while others may allow you to fax or email it.
10. After submitting the imaging request form, the facility will typically contact you to schedule an appointment for the procedure.

Who needs an imaging request form?

1. Individuals who require medical imaging services, such as X-rays, CT scans, MRI scans, etc., will need to fill out an imaging request form. This form helps the imaging facility gather necessary information about the patient and the specific imaging procedure requested.
2. Healthcare providers, including doctors, physicians, specialists, or other medical professionals, may also need to fill out an imaging request form on behalf of their patients. This form allows them to formally request the imaging procedure and provide relevant medical history or details to aid in diagnosis or treatment planning.

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What is imaging request form?

The imaging request form is a document used to request the imaging of a specific body part or area for diagnostic or medical purposes.

Who is required to file imaging request form?

The imaging request form is typically filled out and filed by a healthcare provider such as a doctor or radiologist.

How to fill out imaging request form?

To fill out the imaging request form, the healthcare provider must provide patient information, reason for imaging, and any relevant medical history.

What is the purpose of imaging request form?

The purpose of the imaging request form is to authorize and request specific imaging tests to aid in diagnosis and treatment of medical conditions.

What information must be reported on imaging request form?

The imaging request form must include patient details, reason for imaging, type of imaging test requested, and any relevant medical history.