Free template · PDF
Radiology request form template
An imaging request with the clinical question and the safety checks the radiographer will ask for, answered up front.
Download the PDFFree, no sign-up. Fill it in on screen or print it.
What is on the form
- Practice details, date, recipient and request number
- Patient: name, date of birth, MRN and address
- Priority: routine, urgent or two-week
- Modality: ultrasound, X-ray, CT, MRI, DEXA, mammography, fluoroscopy or other
- Examination requested, side or region, and contrast
- The clinical question
- Safety: pregnancy status, renal function, pacemaker or metal implant, contrast allergy, metformin
- Booking note and sign-off
Using it well
- Phrase the clinical question as the question you want the report to answer.
- Follow the receiving department's own safety screening; this form records the answers, it does not replace their checks.
Less paperwork to fill in at all.
Ask Brigid keeps the diary, the record and the practice paperwork in one place, hosted in AWS Dublin. Practice management for private consultants.
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