Get the free Diagnostic Imaging Requisition Form - St Marys General Hospital

DIAGNOSTIC SERVICES Name: Referring Physician (Print): LAST NAME / FIRST NAME / MIDDLE INITIAL Date of Birth: Address: dd mm by WEB#: Phone #: Health Card #: Copies to: Address: Phone #: () Your privacy

How to fill out diagnostic imaging requisition form

How to fill out a diagnostic imaging requisition form:

1. Start by filling out your personal information, including your full name, date of birth, and contact information. This information is essential for the healthcare provider to identify you and communicate the results.
2. Next, provide your healthcare provider's details, including their name, address, and contact information. This ensures that the diagnostic imaging facility knows where to send the results and whom to contact if there are any questions or concerns.
3. Indicate the reason for the diagnostic imaging test. Specify the symptoms or medical condition that necessitates the imaging procedure. This helps the radiologist understand the purpose of the test and interpret the results accurately.
4. Specify the type of diagnostic imaging test you are requesting. This could include X-rays, CT scans, MRIs, ultrasounds, or any other imaging modality. If you are unsure which test is appropriate, consult your healthcare professional for guidance.
5. Mention any relevant medical history or previous imaging results that may assist the radiologist in interpreting your test. This information can provide valuable context and aid in making an accurate diagnosis.
6. If applicable, provide details of any allergies or sensitivities you may have, particularly to contrast agents used during some imaging procedures. This information helps the facility take necessary precautions to ensure your safety during the test.
7. Finally, sign and date the requisition form to authorize the diagnostic imaging test. Make sure to review the filled form for accuracy and completeness before submission.

Who needs a diagnostic imaging requisition form?

1. Patients who require a diagnostic imaging test to aid in the diagnosis or monitoring of a medical condition may need to fill out a requisition form. This includes individuals experiencing symptoms that require further investigation or those undergoing regular imaging follow-ups.
2. Healthcare professionals, such as physicians or specialists, who are ordering diagnostic imaging tests for their patients, need to complete a requisition form. This form allows them to specify the type of test required and provide necessary clinical information to guide the imaging process and aid in accurate interpretation.
3. Diagnostic imaging facilities or radiology departments require a completed requisition form to schedule and perform the requested imaging examinations. This form serves as a crucial communication tool between the healthcare provider and the facility, ensuring that the right tests are performed on the right patients.

*Disclaimer: The specific requirements and procedures for filling out a diagnostic imaging requisition form may vary depending on the healthcare system and facility. It is always advisable to follow the instructions provided by your healthcare provider and the imaging facility.

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