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All Information MUST BE COMPLETE in Order to Process Referral PATIENT INFORMATION Main number 602 933-1213 Radiology Scheduling 602 933-1215 Fax 602 933-1214 Interventional Scheduling 602 546-4444 Fax 602 933-1587 Imaging Referral Form Please bring this form with you to your appointment Parent/Guardian Name Child s NameDate of Birth Day PhoneEvening PhoneToday s Date InsuranceAuthorization Referring PhysicianReferring Physician Phone Patient s weight Male Female Language Spoken URGENT...

How to fill out imaging referral form

How to fill out an imaging referral form:

1. Start by gathering all the necessary information. This includes the patient's full name, date of birth, and contact information. You should also have the referring physician's details, including their name, specialty, and contact information.
2. Next, identify the reason for the referral. Provide a brief description of the symptoms or condition that necessitates the need for imaging.
3. Specify the type of imaging required. Whether it's an X-ray, MRI, CT scan, or any other form of imaging, make sure to indicate the specific procedure.
4. Include any relevant medical history or current medications that may influence the imaging process or results. This can include known allergies, previous surgeries, or current medications.
5. If there are any specific imaging instructions, such as fasting or required preparations, ensure they are clearly mentioned on the form.
6. Make sure to sign and date the referral form before submitting it. This confirms that it is a valid and authorized request.
7. Finally, submit the completed imaging referral form to the appropriate department or facility as instructed by your healthcare provider.

Who needs an imaging referral form:

1. Patients who require diagnostic imaging for further evaluation of their symptoms or condition may need an imaging referral form. This typically applies to individuals who have visited a healthcare provider and have been referred for imaging services.
2. Healthcare providers, including primary care physicians, specialists, and other medical professionals, may need to fill out an imaging referral form to facilitate the process for their patients. This ensures that the proper tests are ordered and performed to aid in the diagnosis and treatment plan.
3. Imaging centers or facilities also require an imaging referral form to accurately schedule and prepare for the specific imaging procedure requested by the healthcare provider. It serves as a communication tool between the referring physician and the imaging facility, ensuring the necessary information is provided and the appropriate tests are conducted.

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