X ray requisition form 2026

1. Click ‘Get Form’ to open the x-ray requisition form in the editor.
2. Begin by filling out the 'A. PATIENT INFORMATION' section. Enter the patient's Medical Record Number (MRN), Date of Birth (DOB), and Health Card number. Ensure all personal details, including last name, first name, and address, are accurately provided.
3. Indicate the patient's gender and any relevant consent options. If applicable, specify if an interpreter is needed or if there are mobility restrictions.
4. In the 'REQUIRED PATIENT INFORMATION' section, confirm pregnancy status and enter weight and height as required.
5. Proceed to 'B. EXAM INFORMATION'. Fill in the date of request and select the exam requested by checking the appropriate box for right, left, or bilateral examination.
6. Provide detailed clinical information to assist in processing the requisition effectively.
7. Complete 'C. ORDERING PHYSICIAN INFORMATION & SIGNATURE' by entering your name, signature, CPSO number, billing number, fax number, and phone number before submitting.

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