Ultrasound request form template 2026

1. Click ‘Get Form’ to open the ultrasound request form template in the editor.
2. Begin by entering the patient details. Fill in the patient's name, date of birth, address, and contact information. Specify whether the patient is male or female and select their funding source (NHS, self-funded, or private).
3. In the referral information section, indicate the reason for referral and select the type of imaging required (MRI, CT, X-Ray, Ultrasound, Fluoroscopy). Provide details about the area under examination and any relevant medical history.
4. Complete the safety check for MRI examinations. Answer questions regarding pregnancy status, contraindications like pacemakers or allergies, and diabetes management.
5. Fill in the referring clinician’s details including their name, contact information, and signature. Ensure that all required fields are completed before submission.

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