Get X-ray/fluoroscopy Request

Completing the X-Ray/Fluoroscopy Request online is a straightforward process that requires careful attention to detail. This guide will walk you through each section of the form, ensuring that all necessary information is provided for accurate processing.

Follow the steps to successfully complete your request.

1. Press the ‘Get Form’ button to acquire the X-Ray/Fluoroscopy Request form and open it for completion.
2. Fill in the preferred name, including last and first names. Ensure all fields are accurately completed for the form to be processed.
3. Provide your Personal Health Number (PHN) and ensure it matches any previous documents. If the request is for Fluoroscopy and Bone Mineral Densitometry (BMD), note the appropriate fax number.
4. Select your preferred facility and provide the Unique Identifier (ULI), which should correspond to your PHN.
5. Input the Medical Record Number (MRN), patient phone number (preferably a cell number), and your current address including city and postal code.
6. Indicate if there's a Workers' Compensation Board (WCB) claim number and fill in the ordering provider's details, including their name, ID, fax number, and phone number.
7. Specify the department ID and provide a contact number for critical test results. Include the provider's address/location.
8. Enter the date of birth using the format dd-Mon-yyyy and select the appropriate administrative gender.
9. Indicate if a STAT report is requested and whether a copy should be sent to the provider.
10. Complete sections regarding the requested procedure, reason for the exam, clinical questions, and any relevant previous imaging studies.
11. Document the current patient condition, pregnancy status, and any allergies or bleeding disorders, including relevant specifications.
12. Clarify if transportation assistance is required and which type, along with any additional notes regarding the patient’s situation.
13. Provide place for administrative use, including dates received and appointment date/time.
14. Review your entries for accuracy, and then save the changes, download, print, or share the completed form as necessary.

Start completing your X-Ray/Fluoroscopy Request online today for efficient processing.