X Ray Form Chiropractic PDF Details

The X-Ray Chiropractic Form from Life Chiropractic College West Health Center embodies a crucial aspect of patient care in the chiropractic field, streamlining the process for both the healthcare providers and the patients. This comprehensive document captures essential patient information including their name, date of birth, and the attending field doctor's details, alongside the doctor's signature and contact information. It mandates complete details for scheduling, including preferred days and times for the patient, ensuring direct coordination with the office to facilitate appointments efficiently. A notable feature is the inclusion of a variety of X-ray requests, from plain film and digital X-rays to specific requests for a DACBR report, each with detailed specifications for different parts of the body such as cervical, thoracic, and lumbo-pelvic areas. The form also outlines the financial responsibilities, indicating a fee for no-shows and payment options that include billing the doctor's credit card on file or having the patient pay on the day of service. Additionally, there's a sensitive acknowledgment of patient safety with a requirement for female patients to confirm the absence of pregnancy before undergoing any X-ray procedure. This diligent approach underscores the commitment to patient care, safety, and efficient administrative handling within the chiropractic health service framework.

QuestionAnswer
Form NameX Ray Form Chiropractic
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameschiropractic x ray order form, x ray request chiropractic form, x ray form west, x form chiropractic template

Form Preview Example

Life Chiropractic College West Health Center

X-Ray Request Form

Patient Name: _______________________________ M/F

DOB: _____________________

Field Dr.:_____________________________________

Field DR. Acct#: ________________

Mailing address________________________________________________________________________

Dr. Signature: ________________________________ Dr Telephone #: _______________________

-Fill out all fields, list best days and time ranges for patient.

-We will schedule with your office directly. Our phone is 510 780-4559

-FAX this form to us at (510) 780-4511.

-A $25.00 fee may be charged if your patient fails to show up for their appointment.

_____Bill Doctor’s credit card on file

______Patient to pay on day of service

Plain Film X-ray________

 

Digital X-ray (CD for computer) ___________

Request for DACBR report__________ Note: Billed separately by mail

Cervical X rays

 

 

____Ankle (3 views) __Left__Right

____LAT, APOM, APLC (3 views)

 

____Foot (3 views) __Left__Right

____Cervical obliques (2 views)

 

____Knee (2 views) __Left__Right

____Cervical Flex/Ext (2 views)

 

____Hand (3 views) __Left__Right

____Cervical Lateral bending (2 views)

____Wrist (4 views) __Left__Right

 

 

 

____Elbow (3 views) __Left__Right

Thoracic X rays

 

 

____Shoulder(2 views)__Left__Right

____AP, LAT (2 views)

 

 

____Hip ( 2 views) __Left__Right

____Chest PA (1 view)

 

 

____Other____________________________

____Chest LAT (1 view)

 

 

 

Lumbo-pelvic X rays

 

 

Best days/times for patient:

____AP,LAT (2 views)

 

 

 

____Lumbar Flex/Ext (2 views)

 

 

 

____Lumbar obliques (2 views)

 

 

 

____Lumbar Lateral bending (2 views)

 

____Lumbosacral lateral spot (1 view)

 

____PA sacral tilt (1 view)

 

 

 

____Modified Ferguson (1 view)

 

 

 

 

 

______TOTAL number of views

Please do not write below this line:

 

 

Appointment scheduled for:

Date:_________________ Time:________________

For use on day of x ray only by LCCW faculty:

Female Patients: There is no possibility that I am pregnant today.

Patient Signature: ________________________________________ Date: _________________

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Tips on how to prepare chiropractic radiology report template stage 1

2. Once your current task is complete, take the next step – fill out all of these fields - Cervical X rays LAT APOM APLC, Ankle views LeftRight Foot views, Best daystimes for patient, TOTAL number of views, and Please do not write below this with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

chiropractic radiology report template writing process detailed (portion 2)

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Ways to fill in chiropractic radiology report template step 3

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