Orthopedic requisition - Jefferson Radiology 2026

1. Click ‘Get Form’ to open the Orthopedic requisition in the editor.
2. Begin by entering the appointment date and time, ensuring you specify AM or PM.
3. Fill in the patient's name, date of birth, weight, and contact numbers for home, work, and cell.
4. Indicate if the patient has claustrophobia by selecting 'Yes' or 'No'.
5. Provide insurance details including primary and secondary insurance names along with their respective ID numbers.
6. Complete the creatinine section if applicable, noting that it is required for CT contrast for certain patients.
7. Specify the exam requested and list any relevant signs and symptoms using ICD-10 codes as needed.
8. Ensure to have the referring physician's name printed along with their signature at the bottom of the form.

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