Follow the steps to effectively complete the form.

1. Press the ‘Get Form’ button to retrieve the document and open it in your editor.
2. Begin by filling in the patient's information. This includes the patient's name, birthdate, address, city, state, and zip code. Also, provide the home and work phone numbers.
3. Next, indicate the appointment date and time. Ensure that this information is accurate to avoid scheduling conflicts.
4. Enter the physician's details by printing their name, signing the form, and including the physician's phone and fax numbers.
5. Specify if a primary care provider (PCP) referral is required and indicate whether the information has been faxed to the appointment location.
6. Provide a clear reason for the exam tailored to the patient's needs.
7. Select the required radiology procedure from the provided list, making sure to specify the left (L) or right (R) side where applicable.
8. For any specialized imaging requirements like nuclear medicine or ultrasound, fill in the relevant sections, including any specific instructions.
9. Complete any additional information that may help with the exam, ensuring it aligns with the reason for the exam.
10. After filling out all necessary fields, review the form for completeness and accuracy. You can then save changes, download, print, or share the form as needed.

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