Get X-ray Request Form - Alberta Health Services

Filling out the X-Ray Request Form for Alberta Health Services is an essential step for accessing the required imaging services. This guide provides clear, step-by-step instructions to effectively complete the form online, ensuring that all necessary information is accurately submitted.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in an editor.
2. Begin filling out the patient's label section with their last name, first name, and gender, selecting either male or female. Ensure that you provide the full address, including street, city, province, and postal code.
3. Enter the birthdate in the specified format (yyyy-Mon-dd) along with the patient's health number (PHN) and daytime phone number to ensure the receiving facility can contact the patient if needed.
4. Specify the inpatient location if applicable, and include any Workers' Compensation Board (WCB) claim number if relevant.
5. Indicate the preferred facility for the X-ray examination and enter the referring physician's first and last name, along with their phone number, which is a required field.
6. Provide the physician's signature, and check the box to indicate whether a copy of the request should be sent to the physician. Don't forget to include the date in the required format (yyyy-Mon-dd).
7. Indicate if a stat report is requested by selecting either 'Yes' or 'No'. If yes, ensure the physician’s fax number is entered, as this is a required field.
8. Clearly specify the anatomical area to be examined and provide relevant clinical history or presumptive diagnosis, as well as the clinical question that needs to be answered.
9. Include any relevant previous imaging studies that may assist with the current request, particularly for mammography, along with the details of location and type.
10. Thoroughly fill out the current patient condition section, noting allergies, mechanical lift or transfer requirements, and any patient-related information such as pregnancy status or transportation type.
11. Review all fields carefully to ensure accuracy and completeness. This includes confirming the study name, study number, and any additional comments or tech notes needed.
12. Once all sections are completed, you may save changes, download the final document, print it for physical submission, or share it as necessary.

Complete the X-Ray Request Form online today to ensure a smooth process for your imaging needs.