Xray form chiropractic 2026

1. Click ‘Get Form’ to open the x-ray request form in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy for scheduling purposes.
3. Fill in the referring doctor's name and account number, along with their contact information. This is crucial for billing and communication.
4. Indicate whether the patient is male or female by selecting the appropriate option.
5. Provide a mailing address for any correspondence related to the x-ray request.
6. Select the type of x-ray requested (Plain Film or Digital) and specify any additional reports needed, such as a DACBR report.
7. Check off all relevant views required for cervical, thoracic, and lumbo-pelvic x-rays, ensuring you include any specific left/right designations.
8. List the best days and times for the patient’s appointment to facilitate scheduling.
9. Finally, ensure that both the doctor’s signature and patient signature are obtained before submitting. Fax this completed form to the provided number.

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