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It collects attending physician details, patient identification, pregnancy status, and mandatory clinical information. The form provides organized checklists for numerous imaging modalities, including X-ray body regions, mammography and bone densitometry, fluoroscopy, digestive radiology, ultrasound, Doppler studies, CT-scan, and MRI, with options for side (right/left) and specific exams. It also includes scheduling context for appointment versus non-appointment tests.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/physician-request-form-radiology-exam-selection-clinical-information/308002/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/physician-request-form-radiology-exam-selection-clinical-information/308002.png","ImageObject",300,407,{"name":92,"@type":93},"eBook King","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",11,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"What information is required for the clinical part of the radiology request?","Question",{"text":113,"@type":114},"The sheet requires mandatory clinical information, including patient details and pregnancy status where applicable, plus attending physician information and physician signature/licence date.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"How does the form specify which body part or side to image?",{"text":118,"@type":114},"For many modalities and exam categories, it includes checkboxes for specific regions and right/left selection (often marked as R and L) plus optional details like levels or types.",{"name":120,"@type":111,"acceptedAnswer":121},"Which imaging modalities can be requested on this form?",{"text":122,"@type":114},"It supports selection among X-ray, mammography/bone densitometry, fluoroscopy, digestive radiology, ultrasound, Doppler (venous and arterial), CT-scan, and magnetic resonance (MRI), including multiple subtypes and scheduled versus non-appointment options.","https://schema.org",{"og:url":83,"og:type":125,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":127,"canonical":83},"index,follow",{"doc_id":129,"site_id":62},308002,1790010033,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":92,"user_avatar":134,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":105,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":24},962088006270,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","| | |  | \u003Cbr>TROIS-RIVIÈRES 819 373-1603\u003Cbr>TOLL-FREE\u003Cbr>1 866 916-6622 |  |  |  |  | \u003Cbr>PHYSICIAN\u003Cbr>ADDRESS OR STAMP OF ATTENDING PHYSICIAN\u003Cbr>Signature of attending physician required Licence Date |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | REPORT\u003Cbr>q French q English |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| EMAIL\u003Cbr>[rx@imagixmedical.com](rx@imagixmedical.com)\u003Cbr>MONTREAL\u003Cbr>514 866-6622 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| PATIENT |  |  |  |  |  |  |  | CLINICAL INFORMATION (MANDATORY) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Name:   \u003Cbr>D.O. B.:   /   /  \u003Cbr>Tel.:   Email:   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| q CNESST qSAAQ Pregnant q Yes q No |  |  |  |  |  |  |  | Tech.: Nb. X-rays: Fluoro.: Min. Sec. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| The numbers indicate that your examination requires preparation. Please read the instructions for the corresponding number on the back of this sheet. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| X-RAY (without appointment) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| LUNGS / CHEST / RIBS / ABDOMEN q Lungs\u003Cbr>q Thorax q R q L\u003Cbr>q Sternum\u003Cbr>q Abdomen\u003Cbr>SPECIAL EXAMINATIONS\u003Cbr>q Arthritic serie\u003Cbr>q Metastatic serie\u003Cbr>q Other; specify |  |  |  | HEAD / NECK\u003Cbr>q Cranium\u003Cbr>q Sinuses\u003Cbr>q Facial bones\u003Cbr>q Mandible (lower jawbone)\u003Cbr>q Cavum (soft tissues of neck)\u003Cbr>q Nasal bones\u003Cbr>q Orbits\u003Cbr>q Mastoid bones\u003Cbr>q T. M.J. |  |  |  |  |  |  | SPINE / PELVIS\u003Cbr>q Cervical\u003Cbr>q Thoracic\u003Cbr>q Lumbosacral\u003Cbr>q Sacroiliac joints\u003Cbr>q Pelvis\u003Cbr>q Hip q R q L\u003Cbr>q Sacrum\u003Cbr>q Coccyx\u003Cbr>q Scoliosis series |  |  |  | UPPER EXTERMITIES\u003Cbr>q Acromioclavicular joints\u003Cbr>q Sternoclavicular joints |  |  |  |  |  |  |  |  | LOWER EXTREMITIES\u003Cbr>q Femur q R q L\u003Cbr>q Knee q R q L\u003Cbr>q Leg q R q L\u003Cbr>q Ankle q R q L\u003Cbr>q Foot q R q L\u003Cbr>q Toe q R q L specify  \u003Cbr>q Orthodiagraphy (lower extremity measurements)\u003Cbr>specify   |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | q q\u003Cbr>q q\u003Cbr>q q\u003Cbr>q q\u003Cbr>q q |  | Bone age Clavicle Scapula Shoulder\u003Cbr>Humerus\u003Cbr>Elbow\u003Cbr>Forearm\u003Cbr>Wrist\u003Cbr>Hand\u003Cbr>Finger |  |  | q q\u003Cbr>q q\u003Cbr>q q\u003Cbr>q q\u003Cbr>q | R\u003Cbr>R\u003Cbr>R\u003Cbr>R\u003Cbr>R\u003Cbr>R\u003Cbr>R\u003Cbr>R\u003Cbr>R | q q\u003Cbr>q q\u003Cbr>q q\u003Cbr>q q\u003Cbr>q | L\u003Cbr>L\u003Cbr>L\u003Cbr>L\u003Cbr>L\u003Cbr>L\u003Cbr>L\u003Cbr>L\u003Cbr>L |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| MAMMOGRAPHY / BONE DENSITOMETRY (with appointment) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| q Diagnostic (clinical information is essential) \u003Cbr>q Enlargements/Complementary Images  q Right q Left\u003Cbr>q Screening ages 50 to 69 (PQDCS) \u003Cbr>q Screening ages 35 to 49, age 70 and over  |  |  |  |  |  |  | |  |  | \u003Cbr>\u003Cbr>\u003Cbr>Right Left |  |  |  | | q Bone densitometry (including thoracolumbar Date of last examination: |  |  |  |  |  |  |  |  |  | spine profile)\u003Cbr>YYYY / MM / DD |\n| FLUOROSCOPY (with appointment) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| DISGESTIVE RADIOLOGY\u003Cbr>q Esophagus  q Barium enema \u003Cbr>q Barium meal  q Small bowel series \u003Cbr>q Pharynx + Esophagus (swallowing)  |  |  |  |  |  |  | INFILTRATION MUSCULOSKELETAL\u003Cbr>q Arthrography therapeutic (injection) \u003Cbr>q Distension arthrogram \u003Cbr>q Facet block  |  |  |  |  |  |  |  |  | q R q R q R |  |  | q L Specify:   q L\u003Cbr>q L Level (s):   |  |  |  |  |  |  |\n| ULTRASOUND (with appointment) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | OBSTETRICAL (with appointment) |  |  |  |  |  |  |  |  |  |\n| q Abdominal \u003Cbr>q Transvesical pelvic (and endovaginal if necessary)  A\u003Cbr>q Spinal\u003Cbr>q Surface |  |  |  |  |  | q Thyroid q Breast\u003Cbr>q Cardiac* q","cbCainzOHsPbeO69","https://ap.wps.com/l/cbCainzOHsPbeO69","pdf",352460,"English","# Clinical Information (Mandatory)\n## Patient details and pregnancy status\n## Imaging selection by modality (X-ray, Mammography, Fluoroscopy, Ultrasound, Doppler, CT-Scan, MRI)","[{\"question\":\"What information is required for the clinical part of the radiology request?\",\"answer\":\"The sheet requires mandatory clinical information, including patient details and pregnancy status where applicable, plus attending physician information and physician signature/licence date.\"},{\"question\":\"How does the form specify which body part or side to image?\",\"answer\":\"For many modalities and exam categories, it includes checkboxes for specific regions and right/left selection (often marked as R and L) plus optional details like levels or types.\"},{\"question\":\"Which imaging modalities can be requested on this form?\",\"answer\":\"It supports selection among X-ray, mammography/bone densitometry, fluoroscopy, digestive radiology, ultrasound, Doppler (venous and arterial), CT-scan, and magnetic resonance (MRI), including multiple subtypes and scheduled versus non-appointment options.\"}]","Physician Request Form - Radiology Exam Selection - Clinical Information | PDF",1789858489]