Request Form

When an imaging study is required a request form is filled out by the referring physician. Every practice will have its own specific version but all requests must contain certain specific information such as the examination required, patient name and patient location. Requests are usually in written form but hospitals with a PACS system installed may have digital requests.

Imaging procedures cannot be done without a request. Performing a procedure without a request may lead to fines, disqualification of radiation licence, dismissal and possible litigation.

Below is a sample request form for a chest xray at wikiradiography medical centre.

wikiradiography medical centre request form
Sample request form key

  1. Name of the institution or radiology practice where the procedure is to be conducted
  2. Name of the patient, including UR number, date of birth, gender and home address
  3. Indicates if the patient is ambulant, arriving in a wheel chair or confined to a bed
  4. Any allergies applicable to the imaging procedure eg: allergy to contrast media
  5. The name of the referring doctor, their signature and date of request
  6. Contact details of referring doctor, in this case an internal pager number is given
  7. Clinical details of the patient, to enable the radiographer to perform the most beneficial views and information for the radiologist to assist with reporting.
  8. indicates if previous imaging studies been performed for this patient, at this department, old films are an excellent source of information as they enable you to compare images over time.
  9. What examination has been requested eg: chest xray
  10. Where is the patient located eg: Emergency Department
  11. The head of the department of the referring doctor, often for billing purposes

Topics related to this article



AndyC
AndyC
Latest page update: made by AndyC , Feb 18 2008, 9:11 AM EST (about this update About This Update AndyC Edited by AndyC

1 image added
1 image deleted

view changes

- complete history)
More Info: links to this page

Related Content

  (what's this?Related ContentThanks to keyword tags, links to related pages and threads are added to the bottom of your pages. Up to 15 links are shown, determined by matching tags and by how recently the content was updated; keeping the most current at the top. Share your feedback on Wetpaint Central.)
Site pages
Top Contributors