About this template
A radiology requisition form is an essential document used by physicians, nurses, and medical staff to order diagnostic imaging procedures such as X-rays, MRIs, CT scans, and ultrasounds. This structured digital template ensures that all necessary clinical details—including patient demographics, clinical history, contrast requirements, and urgency status—are accurately captured before an exam is scheduled.
Designed to streamline clinical workflows, this Google Form template eliminates messy paper orders and reduces communication delays between referring providers and imaging departments. It prompts the ordering practitioner for critical safety information, such as allergy histories, anesthesia needs, and patient transport status, helping imaging centers prepare properly and maintain high standards of patient safety.
With Doc2Form, medical practices can quickly customize this requisition template to match their clinic or hospital requirements. Once deployed, referring clinicians or intake coordinators can submit orders seamlessly from any device, allowing your team to review requests, verify insurance or clinical justification, and schedule diagnostic appointments faster than ever.
Key features
- Streamline diagnostic imaging orders from requisition to scheduling.
- Capture critical clinical history, diagnoses, and relevant symptoms.
- Check for contrast allergies and anesthesia requirements in advance.
- Specify procedure urgency and patient transport needs instantly.
- Easily customize fields to match your clinic or hospital protocols.
Use cases
- Outpatient clinics ordering routine X-rays and ultrasounds.
- Hospital departments coordinating emergency MRI and CT scans.
- Specialists requesting specialized imaging for diagnostic workups.
- Inter-facility patient transfers requiring prior imaging records.
What this form collects
- 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.
- Phone Number (Short answer)Enter the best contact number for the patient.
- Patient Address (Paragraph)Provide the patient's current residential address.
- Urgent Patient Status (Multiple choice)Indicate the urgency level required for this imaging procedure.
- Anesthesia Status (Multiple choice)Will the patient require anesthesia during the procedure?
- Laterality (Multiple choice)Specify the side of the body applicable to the imaging study.
- Transport Requirements (Multiple choice)Select how the patient will arrive at the radiology department.
- Contrast Status (Multiple choice)Is intravenous or oral contrast required for this exam?
- Modality Selection (Dropdown)Select the requested imaging modality.
- Allergy Status (Multiple choice)Does the patient have any known allergies (especially to contrast media, iodine, or latex)?
- Allergy List (Paragraph)If the patient has allergies, please list them and note previous reactions.
- Diagnosis or Relevant Clinical History (Paragraph)Provide relevant symptoms, clinical notes, ICD-10 codes, or suspected diagnosis justifying this exam.
FAQ
How do I share this radiology requisition form with referring physicians?
You can easily share the Google Form via a direct link, embed it on your internal intranet portal, or send it directly to medical staff via email.
Can I customize the list of imaging modalities and exam types?
Yes! You can edit, add, or remove any imaging options (such as MRI, CT, X-ray, or Ultrasound) to perfectly match the equipment and services available at your facility.
How does Doc2Form help me manage these requisitions?
Doc2Form lets you instantly convert this template into a fully functioning Google Form, allowing you to centralize all imaging requests directly in Google Sheets for effortless tracking and review.
Is patient health information secure?
Google Forms uses robust encryption standards in transit and at rest. Ensure your workspace account complies with your organization's internal data governance policies before collecting sensitive patient details.
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.