About this template
An Outpatient Imaging Order Form is essential for healthcare providers and clinics looking to streamline diagnostic imaging requests. Whether you are ordering an X-ray, MRI, CT scan, or ultrasound, this template captures all necessary clinical details, patient demographics, and referring practitioner information in a single, organized submission.
Designed specifically for medical offices, diagnostic centers, and hospitals, this digital form eliminates messy paper requisitions and reduces phone tag between facilities. Referring physicians can clearly specify clinical indications, affected body parts, and urgency levels, ensuring patients receive the correct tests without administrative delays.
Using Doc2Form, you can instantly turn this template into a live Google Form, making it effortless to collect, review, and archive imaging requests directly within your workspace.
Key features
- Capture patient demographics and clinical history in one organized step.
- Specify imaging modality, exact body parts, and clinical indications clearly.
- Indicate test urgency to prioritize critical diagnostic scans.
- Collect referring practitioner NPI and contact details for seamless communication.
- Instantly deployable as a ready-to-use Google Form.
Use cases
Primary care physicians referring patients for outpatient MRI or CT s…
Primary care physicians referring patients for outpatient MRI or CT scans.
Specialists requesting targeted X-rays or ultrasounds before follow-u…
Specialists requesting targeted X-rays or ultrasounds before follow-up appointments.
Diagnostic imaging centers receiving electronic requisitions from loc…
Diagnostic imaging centers receiving electronic requisitions from local clinics.
What this form collects
- Order Date (Date)Select today's date.
- Patient Full Name (Short answer)Enter the patient's first, middle, and last name.
- Date of Birth (Date)Enter the patient's date of birth.
- Home Phone Number (Short answer)Enter the primary contact number for the patient.
- Alternative Phone Number (Short answer)Enter a work or cell phone number if available.
- Referring Practitioner Name (Short answer)Enter the full name of the ordering physician.
- NPI Number (Short answer)Enter the 10-digit National Provider Identifier.
- Practitioner's Phone Number (Short answer)Enter the direct office phone number for queries.
- Practitioner's Fax Number (Short answer)Enter the secure fax number for report delivery.
- Type of Imaging (Dropdown)Select the required imaging modality.
- Body Part to be Imaged (Short answer)Specify the exact anatomical site and lateralize if applicable (e.g., Left Knee, Chest, Brain).
- Clinical Indication / Reason for Exam (Paragraph)Provide signs, symptoms, ICD-10 codes, or relevant medical history supporting this request.
- Urgency (Multiple choice)Select the priority level for this imaging order.
- Special Instructions (Paragraph)Include any contrast allergies, patient mobility notes, or special protocols.
- Physician's Signature & Authorization (Short answer)Please type the full name of the ordering physician to serve as digital authorization, or paste a link to a signed requisition document.
- Date of Signing (Date)Enter the date of authorization.
FAQ
How do I customize this form for my clinic?
With Doc2Form, you can instantly generate this template as a Google Form and use Google's native editor to add your facility's logo, adjust fields, or include specific imaging protocols.
Is this form template free to use?
Yes! You can instantly convert this template into a functional Google Form at no cost using Doc2Form.
Can referring physicians submit this from mobile devices?
Yes, Google Forms are fully responsive and work seamlessly on smartphones, tablets, and desktop computers.
How do I collect physician signatures?
While standard Google Forms collect text-based acknowledgments or electronic sign-off names, you can also include a file upload link field for signed PDF requisitions if required by your compliance standards.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.