X Ray Form Chiropractic PDF Details

Chiropractic is a form of therapy that focuses on the alignment of the spine and nervous system. Chiropractors use a variety of techniques to adjust the spine and relieve pressure on the nerves. X-rays are often used to help diagnose misalignments in the spine. In this blog post, we will discuss how chiropractors use x-rays to diagnose problems and provide treatment options. We will also explore some of the benefits of chiropractic care. If you are considering chiropractic treatment, be sure to talk to your doctor about whether it is right for you.

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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1. To start with, while filling in the xray form chiropractic fill, start with the page containing next blank fields:

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)

Regarding Please do not write below this and TOTAL number of views, be certain that you don't make any errors in this current part. The two of these could be the key fields in the form.

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Ways to fill in chiropractic radiology report template step 3

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