Ohsu Imaging Order Form - Fill Online, Printable, Fillable, 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient demographics. Fill in the patient's name, date of birth, height, weight, and phone number in the designated fields.
3. Next, provide the referring physician's name and signature. Indicate whether the order is urgent or routine by checking the appropriate box.
4. Complete the ICD-10 code and description sections to specify the diagnosis related to the imaging request.
5. Fill out any additional information required, including authorization numbers and expected dates for results.
6. Check all applicable boxes regarding patient needs such as physical assistance or interpreter services.
7. Specify any implants or allergies that may affect imaging procedures in the relevant sections.
8. Finally, review all entries for accuracy before saving or printing your completed form.

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