Medical imaging exam request form - Intermountain Healthcare - intermountainhealthcare 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'Appointment Details' section. Select the clinic location and enter the date and time for the appointment.
3. In the 'Patient Information' section, provide the patient's name, date of birth, contact numbers, insurance company, and email address.
4. Next, complete the 'Referring Physician Information' by entering the physician's name, office phone number, and signature with date and time.
5. Indicate any sedation requirements by checking the appropriate box under 'Sedation recommended for'.
6. Clearly state the reason for the imaging procedure in the designated area. Be specific to ensure proper examination.
7. Select the type of exam required from options provided under 'Exam Type', ensuring all relevant boxes are checked.
8. Finally, review all entries for accuracy before saving or sending your completed form through our platform.

Start using our platform today to streamline your medical imaging requests effortlessly!