About this template
A radiology order form is an essential clinical document used by physicians and medical clinics to request diagnostic imaging services, such as X-rays, MRIs, CT scans, and ultrasounds, for their patients. This standardized template captures vital clinical details, including patient demographics, medical record numbers, ordering physician information, clinical history, and the specific area of interest.
Streamlining the diagnostic imaging request process helps eliminate lost paperwork, reduces transcription errors, and ensures that imaging centers have the complete clinical context required before the patient arrives. Medical practices, hospitals, and outpatient clinics can use this streamlined digital format to accelerate scheduling and improve communication between referring physicians and radiology departments.
Doc2Form makes it simple to deploy this template as a ready-to-use Google Form, allowing medical staff to securely gather and organize requests in one place without complex setup.
Key features
- Capture patient demographics and medical record numbers securely.
- Specify exact areas of interest and clinical history.
- Indicate urgency for priority imaging scheduling.
- Collect complete ordering physician contact and license details.
Use cases
- Outpatient clinic imaging requests sent to local hospitals.
- Internal hospital referrals from primary care to radiology departments.
- Specialist diagnostic test scheduling and documentation.
What this form collects
- Patient Full Name (Short answer)Enter the patient's first, middle, and last name.
- Date of Birth (Date)Select the patient's date of birth.
- Gender (Multiple choice)Select the patient's gender.
- Patient Phone Number (Short answer)Enter a reliable contact number for scheduling the appointment.
- Patient Email (Short answer)Enter the patient's email address for appointment notifications.
- Medical Record Number (MRN) (Short answer)Enter the patient's unique medical record or chart number.
- Ordering Physician Full Name (Short answer)Enter the name of the licensed physician requesting the imaging.
- Physician Phone Number (Short answer)Enter the direct phone number or clinic extension for clinical inquiries.
- Physician Email (Short answer)Enter the ordering physician's professional email address.
- History / Reason for Exam (Paragraph)Provide the relevant clinical history, symptoms, and diagnostic justification.
- Exact Area of Interest (Short answer)Specify the anatomical site or side (e.g., left knee, chest, brain) to be imaged.
- Imaging Questions (Paragraph)Note any specific clinical questions the radiologist should address in the report.
- Requested Tests (Checkboxes)Select all diagnostic imaging modalities requested.
- Clinically Urgent Tests (Multiple choice)Indicate if this order requires expedited or STAT processing.
- Physician Signature / Authorization (Paragraph)Please paste a link to your signed authorization form or type your full legal name to serve as a digital signature.
- Physician Signature Date (Date)Select the date the order was authorized.
FAQ
How do I use this radiology order form template?
Click to instantly convert and copy this template directly into your Google Drive as a new Google Form, ready to customize and share with referring physicians.
Can I customize the list of requested imaging tests?
Yes, you can easily edit the Google Form to add, remove, or modify test options like X-ray, MRI, CT, ultrasound, or specialized scans.
Is patient health information secure?
Responses are stored securely within your organization's Google Drive account, adhering to standard Google Workspace security practices.
Can ordering physicians attach supporting documents?
You can add a file upload or text prompt allowing physicians to link relevant clinical notes, prior imaging reports, or insurance authorizations.
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.