Imaging Request Form (PDF) - Centre for Health - centreforhealth org 2026

1. Click ‘Get Form’ to open the Imaging Request Form in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the address, home number, postcode, and ID/NHS number. This data helps in processing the request efficiently.
4. Provide work or mobile numbers for additional contact options. This ensures that you can be reached if further information is needed.
5. Indicate the examination requested by checking the appropriate box for X-Ray, Ultrasound, or MRI. Include any relevant clinical details regarding surgery and current medications.
6. If contrast is required, enter the creatinine level and date of test to ensure patient safety.
7. The referrer must complete their declaration by signing and printing their name, confirming all necessary details are accurate.
8. Finally, ensure that both patient and operator signatures are obtained before submitting the form to the Medical Imaging Partnership.

Start using our platform today to fill out your Imaging Request Form easily and for free!