Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin filling out the patient information section. Enter the patient's full name, phone number, and date of birth. Make sure all details are accurate.
3. Specify the appointment date and time by selecting the appropriate values from the provided fields.
4. Indicate the medical plan by selecting the relevant option from the list. If 'Other' is chosen, provide the name of the plan in the space provided.
5. Complete the diagnosis and clinical history field, ensuring that the information is detailed as it is mandatory for processing.
6. If applicable, list any prior studies for the same body part, including the date they were performed.
7. Fill in the referring physician's contact information, including their phone and fax numbers.
8. Include the name of the referring physician and their signature in the designated fields.
9. If contrast studies apply, ensure that any recent BUN and creatinine levels are provided for patients over 55 or with risk factors.
10. In the imaging section, select the appropriate studies required — including MRI, CT, ultrasound, and others — based on the patient's needs.
11. For any special instructions from the doctor, use the provided space to add detailed notes.
12. Choose your preferred report type: Report Only, Report with CD, or Report with Films, and provide necessary contact information for report delivery.
13. Review all provided information for completeness and accuracy, then save your changes.
14. Finally, download, print, or share the completed form as needed.

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