Get Life Chiropractic College West Health Center X-ray Request Form

Filling out the Life Chiropractic College West Health Center X-Ray Request Form online is a straightforward process that ensures patients receive the necessary imaging services efficiently. This guide will help you navigate each section of the form clearly and effectively.

Follow the steps to complete the form online seamlessly.

1. Locate and press the ‘Get Form’ button to access the form and open it in your document editor.
2. Begin by entering the patient's name in the designated field at the top of the form.
3. Input the referring doctor's name in the 'Field Dr.' section.
4. Select the appropriate gender option by marking either M or F.
5. Fill in the patient's date of birth (DOB) in the specified field.
6. Provide the referring doctor’s account number in the associated field.
7. Enter the mailing address where the report should be sent.
8. The doctor must sign the form in the designated ‘Dr. Signature’ field and provide their telephone number.
9. Indicate the best days and time ranges for the patient’s appointment in the allocated area.
10. Specify the payment option by checking the relevant box for billing the doctor's credit card or choosing the patient to pay on the day of service.
11. Select the type of X-ray to be requested by marking either 'Plain Film X-ray' or 'Digital X-ray' options accordingly.
12. For the report, check the box if a DACBR report is requested, keeping in mind that this will be billed separately by mail.
13. Indicate the specific X-rays needed by marking each relevant checkbox based on the categories provided (Cervical, Thoracic, Lumbo-pelvic, etc.). Ensure to specify left or right when needed.
14. Count the total number of views required and enter that information in the appropriate field.
15. Complete the area that states the appointment scheduling, which includes spaces for date and time.
16. For female patients, confirm the statement regarding pregnancy by marking the box provided.
17. Finally, the patient must sign and date the form in the appropriate section.
18. After completing all sections of the form, review all entries for accuracy and save your changes. You can then download, print, or share the completed form.

Complete your documents online with confidence and ensure your requests are handled smoothly.