Get General Radiography (x-ray) Request Form - Alberta Health Services

Filling out the General Radiography (X-Ray) Request Form online can streamline the process of requesting imaging services. This guide provides clear, step-by-step instructions for completing the form accurately and efficiently.

Follow the steps to fill out your X-ray request form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the patient label information required, including the last name and first name.
3. Input the patient's birthdate in the format yyyy-Mon-dd.
4. Select the gender by marking either Male or Female.
5. Fill in the address details, including street, city, province, and postal code.
6. Indicate if a stat report is requested by selecting 'Yes' or 'No'.
7. Provide the personal health number (PHN) of the patient.
8. Select the preferred facility for conducting the X-ray examination.
9. Enter the date of the request in the format yyyy-Mon-dd.
10. Specify the anatomical area to be examined.
11. Provide a daytime phone number for contact purposes.
12. If the patient is an inpatient, include the relevant location details.
13. Fill in the referring physician’s information, including their first and last name, signature, and phone number.
14. Enter the WCB claim number if applicable.
15. Provide a fax number for the referring physician.
16. If a copy of the report is to be sent to another physician, fill in their details.
17. Detail the relevant clinical history or presumptive diagnosis.
18. State the clinical question to be answered by the imaging.
19. Input details of any relevant previous imaging studies, including location and type.
20. Describe the current patient condition and whether there are any isolation precautions.
21. Indicate any known allergies.
22. If applicable, note if the patient is participating in a research study.
23. Specify if the patient is pregnant and provide the last menstrual period (LMP) date.
24. Select the type of transportation needed for the patient (e.g., ambulatory, wheelchair, stretcher, etc.).
25. Indicate the study name and study number, if available.
26. Provide details regarding beta HCG, if applicable.
27. In the department use section, enter the date and time format as required.
28. Finally, review the entire form for accuracy and completeness before saving.

Complete your X-ray request form online today for efficient processing.