Get Patient Referral Form Request For Radiology Imaging Amp Reporting - Dental Pitt

Filling out the patient referral form for radiology imaging and reporting is an essential process for ensuring proper patient care. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and efficiently in an online environment.

Follow the steps to successfully complete the patient referral form.

1. Click ‘Get Form’ button to obtain the form and open it in your chosen editing tool.
2. Enter today’s date in the designated field. This helps in keeping track of the referral timeline.
3. Specify the date of imaging by filling it in the appropriate field. This ensures that the imaging is scheduled correctly.
4. Fill in the patient's name, including first, middle initial, and last names. Be certain to provide accurate details for identification.
5. Provide the patient's address, which assists in communication and record-keeping.
6. Indicate the patient's age and birthdate; this information is crucial for age-related assessments.
7. Insert the patient's phone number for follow-up communication, ensuring it is formatted correctly.
8. Select the sex of the patient by marking the appropriate option, as this may be relevant for certain imaging studies.
9. Complete the referring clinician's information by including their name, address, phone number, fax number, and email address for correspondence.
10. Document relevant history and clinical notes in the specified sections. This provides important context for the imaging evaluation.
11. Check appropriate fields regarding the imaging type required, such as plain radiographs or CBCT, and provide details on specific requests.
12. Mention any restricted scan requirements if applicable, indicating the specific areas concerned.
13. Fill in any special instructions or areas of clinical interest that the radiology team should consider during imaging.
14. Indicate if the patient is bringing a radiographic template or any necessary diagnostic models, marking the relevant checkboxes.
15. Provide details for electronic transfer options and specify doctor’s email for report delivery.
16. Ensure that the doctor’s signature and date are affixed at the bottom of the form. This finalizes the referral process.
17. After completing the form, review all entries for accuracy, then save changes, download, print, or share the form as required.

Complete your patient referral form online today to ensure timely and effective imaging services.