Get Radiology Order Form

Filling out the Radiology Order Form online can streamline the process of scheduling diagnostic procedures. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the Radiology Order Form online:

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information. Print the patient’s full name in the designated fields, including last name, first name, and middle initial. Provide the patient’s date of birth and medical record number.
3. Indicate the patient's gender by checking the appropriate box for Male or Female. Fill in the patient’s contact information, including home, cell, and work telephone numbers.
4. Include the patient's insurance details by listing the insurance provider and the subscriber number.
5. Document the diagnosis information along with the primary care provider's name. Write the diagnosis codes and indicate to whom the report should be sent.
6. In the clinical history section, provide relevant patient medical history that may impact the procedures.
7. For procedure information, check the appropriate box for the requested procedure, such as consultation, vertebroplasty, biopsy, or any other specified procedures.
8. Specify any guidance needed for biopsies (e.g., fluoroscopy, ultrasound, CT) and note any complications or health conditions like diabetes or blood thinner medication.
9. Complete the section for the ordering provider, including their name, office phone number, and fax number.
10. Lastly, date and sign the form in the space provided for the ordering provider's signature.
11. Once all sections are completed, you can save changes, download, print, or share the form as needed.

Start filling out the Radiology Order Form online today for a smooth submission experience.