Free template
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 it asks for
What is on the formThe secretary completes
- 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.
Open it in the sample practice
The sample practice is the real Ask Brigid on invented patients, open without a sign-up. This document joins its Library with the next sample-practice update; the Library already holds the practice’s templates.
Sources
- The shipped template's field list (Brigid stationery v12), read 24 October 2026
Checked against the sources above on 23 September 2026. Issuers change their forms; check the official page before you rely on a detail here.
In Ask Brigid this paperwork sits beside the diary and the record: Practice management for private consultants.