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Radiology Order Form Template

Streamline Your Imaging Requests with Our User-Friendly Template

Submitting imaging requests can be time-consuming and prone to error, causing delays in patient care. This radiology order form template is designed for healthcare professionals who need to request X-rays, MRIs, and other imaging services efficiently. It simplifies the collection of patient details, specifies imaging requirements, and ensures compliance with radiology protocols, all while maintaining clear communication with your team. With its WCAG-aligned labels for accessibility, you can create accurate and professional orders in minutes. Try using the live template and see the difference!

Use this Template (FREE) Live Preview
Ordering provider full name
NPI number
Practice or facility name
Provider phone
Provider fax (for results)
Patient full name
Date of birth
Patient phone
Patient ID or MRN (if available)
Imaging modality requested
X-ray
Ultrasound
CT
MRI
Mammography
Nuclear medicine
DEXA (bone density)
Fluoroscopy
Other
Please Specify:
Body part or region to image
Laterality
Left
Right
Bilateral
Midline
Not applicable
Clinical indication / reason for exam
ICD-10 code(s) (if known)
Contrast use
Without contrast
With contrast
With and without contrast
As per radiologist protocol
Not applicable
Pregnancy status (if applicable)
Not applicable
Not pregnant
Possibly pregnant
Pregnant
Unknown
Prefer not to say
Known allergy to iodinated or gadolinium contrast
Yes
No
Unknown
Implanted devices or metal (select all that apply)
Renal impairment or eGFR < 30 in last 30 days
Yes
No
Unknown
Not tested
Preferred date for exam
Preferred imaging location or site
Priority
Routine (within 7-14 days)
Expedited (within 72 hours)
Urgent/STAT (today)
Flexible / next available
Primary insurance payer
Member ID / Policy number
Prior authorization status
Approved
Pending
Not required
Denied
Unknown
Patient consent obtained for contrast (if applicable)
Yes
No
Not applicable
Unknown
Ordering provider electronic signature (type full name)
Date signed
I attest that the information provided is accurate and that I am authorized to order this imaging study
True
False
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Paper art illustration featuring a radiology order form with medical icons and layouts for FormCreatorAI article.

When to use this form

Use this form when you need to order imaging such as X-ray, CT, MRI, or ultrasound with a clear clinical question. It helps you specify the exact study, body area, and urgency so radiology can use the right protocol. Typical cases include a suspected wrist fracture, pneumonia follow-up, kidney stone evaluation, or pre-op chest study. If imaging is needed after an inpatient stay, pair your order with the Hospital discharge form. To prevent duplicate scans, include prior reports or films via the Transfer of medical records form. A complete order speeds scheduling, reduces call-backs, and ensures contrast screening and prep instructions are clear for your patient.

Must Ask Radiology Order Questions

  1. What is the clinical indication and relevant history?

    This tells the radiologist what you are trying to confirm or rule out, which guides protocol and reporting. Clear context reduces repeat imaging and helps produce an actionable report.

  2. Which imaging study and body area are needed, including side and views?

    Stating modality (e.g., CT), body part, laterality (right/left), and views prevents wrong or incomplete exams. Precise instructions like "right wrist, 3 views" or "CT abdomen and pelvis" improve first-time accuracy.

  3. Is contrast requested, and does the patient have any safety risks (allergies, kidney disease, pregnancy, or implants)?

    This ensures safe contrast use and flags MRI or radiation contraindications before scheduling. It allows the team to obtain labs, arrange premedication, or choose a safer alternative when needed.

  4. How urgent is the study and who should receive results?

    Marking STAT, urgent, or routine helps triage and allocate scanner time appropriately. Adding the best contact for critical results speeds care and closes the communication loop.

  5. Are there any infectious precautions, such as suspected or confirmed COVID-19?

    Infection status affects room prep and scheduling to keep patients and staff safe. If relevant, attach documentation such as the COVID 19 positive diagnosis form to align testing and imaging logistics.

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