Get the free X-Ray and Ultrasound Requisition Form LHSC - MRI Appointments

PIN UNIT ROOM# RADIOLOGIC CONSULTATION Name: University Hospital South Street Hospital Victoria Hospital Previous exam at LHC: Yes No (if no, indicate where and date) SITE: Where: LAST FIRST ADDRESS

How to fill out x-ray and ultrasound requisition

How to fill out an X-ray and ultrasound requisition:

1. Start by filling in the patient's personal information, such as their name, date of birth, and contact details.
2. Indicate the reason for the requested X-ray or ultrasound. Provide relevant medical history or symptoms that justify the need for these diagnostic tests.
3. Specify the type of examination required. If it is an X-ray, mention the specific body part or area that needs imaging. For an ultrasound, state the organ or system that needs to be evaluated.
4. Include any additional instructions or special considerations for the radiologist or sonographer performing the procedure. This may include specific imaging protocols, required positions, or patient preparations.
5. If applicable, indicate any previous imaging studies or medical tests that are relevant to the current request. This can help provide a comprehensive view of the patient's medical history.
6. Provide your contact information as the healthcare provider making the request. Include your name, professional title, and contact number in case there are any questions or clarifications needed.
7. Sign and date the requisition form to confirm the ordering healthcare provider's approval and responsibility for the requested examinations.
8. Make a copy of the completed form for your records and submit the original requisition to the appropriate department or facility.

Who needs an X-ray and ultrasound requisition:

1. Patients who require further diagnostic evaluation beyond physical examination and medical history.
2. Healthcare providers who suspect underlying medical conditions or injuries that cannot be conclusively diagnosed without the aid of X-ray or ultrasound imaging.
3. Individuals with symptoms such as pain, swelling, or abnormalities in specific body regions that require further investigation.
4. Patients with known medical conditions or previous imaging findings that necessitate periodic monitoring or follow-up examinations.
5. Individuals scheduled for surgical procedures or interventions that require pre-operative imaging assessments.
6. Patients participating in research studies or clinical trials that require baseline or follow-up imaging as part of the study protocol.
7. Healthcare providers who require imaging for treatment planning or to guide interventions.
8. Patients referred by other medical specialists seeking specific diagnoses or to rule out certain conditions.

Please note that the specific criteria for needing an X-ray or ultrasound requisition may vary depending on healthcare systems, regional guidelines, and individual patient circumstances. It is always essential to consult with a qualified healthcare provider to determine the appropriateness and necessity of these diagnostic tests.

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