| Imaging Request Form |
When an imaging study is required a request form is filled out by the referring physician. Every practice will have its own specific version but all requests must contain certain specific information such as the examination required, patient name and patient location. Requests are usually in written form but hospitals with a PACS system installed may have digital requests.
Imaging procedures cannot be done without a request. Performing a procedure without a request may lead to fines, disqualification of radiation licence, dismissal and possible litigation.
Below is a sample request form for a chest xray at wikiradiography medical centre.
Sample request form key
- Name of the institution or radiology practice where the procedure is to be conducted
- Name of the patient, including UR number, date of birth, gender and home address
- Indicates if the patient is ambulant, arriving in a wheel chair or confined to a bed
- Any allergies applicable to the imaging procedure eg: allergy to contrast media
- The name of the referring doctor, their signature and date of request
- Contact details of referring doctor, in this case an internal pager number is given
- Clinical details of the patient, to enable the radiographer to perform the most beneficial views and information for the radiologist to assist with reporting.
- indicates if previous imaging studies have been performed for this patient at this department, old films are an excellent source of information as they enable you to compare images over time.
- What examination has been requested eg: chest xray
- Where is the patient located eg: Emergency Department
- The head of the department of the referring doctor, often for billing purposes
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