X Ray Referral Form
Capture every referral detail before the patient leaves the room, so imaging teams receive complete requests every time.
Imaging departments receiving faxed x-ray referrals often find missing indications or illegible notes that require a callback before booking. Every callback is a delay in patient care. Typeform's x-ray referral form gives clinicians a reliable way to submit complete, structured referrals from any device.
The form captures patient details, body region, clinical indication, relevant history, urgency level, and referring clinician details in one submission. The one-question-at-a-time format reduces the risk of incomplete submissions for clinicians working quickly between patients. Conditional logic surfaces additional clinical fields based on the referring clinician's answers. A referral marked as urgent triggers fields for urgency reason and preferred imaging timeframe, while routine referrals move straight through.
Customize the form with your practice name, imaging providers, referral categories, and any clinical fields specific to your specialty. Share it as a direct link in your clinical management system or include it in your patient booking workflow. Connect it to Google Sheets via Zapier so every referral logs automatically with patient details, body region, and urgency. Imaging teams receive complete referrals, keeping patient care moving.
An x-ray referral form captures the clinical information an imaging department needs to process and schedule an x-ray request. It gathers patient details, the body region, clinical indication, relevant history, urgency, and the referring clinician's details in one submission. It functions as the official referral record between the referring clinician and the imaging provider.
Incomplete x-ray referrals waste time at both ends of the process. When the indication or urgency is missing, the imaging team calls before the scan can be booked. A structured form ensures every referral arrives with the information needed to book and prepare. Use it for GP practices, specialist clinics, and any setting where imaging referrals are made to an external provider.
A complete x-ray referral form covers:
- Patient full name, date of birth, and contact details
- Referring clinician's name, practice, and contact
- Referral date and urgency level
- Body region to be imaged (e.g., chest, spine, extremity)
- Clinical indication and presenting complaint
- Relevant medical history or prior imaging
- Preferred imaging provider or location (if applicable)
- Any contraindications (e.g., pregnancy, implants)
Set up conditional logic to branch by urgency, so urgent referrals trigger additional fields before submission. A clinician marking the referral urgent sees prompts for urgency reason, preferred timeframe, and relevant clinical notes. A routine referral moves straight to submission. Imaging teams receive everything they need before they pick up the phone.
Typeform's File Upload feature lets clinicians attach relevant prior imaging reports, investigation results, or clinical notes directly in the referral. Accepted file types include PDF, JPG, and PNG, with a 10MB limit per file. Documents arrive alongside each referral's clinical details, so the imaging team reviews the full clinical picture in one place. File Upload is available on paid Typeform plans.
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