Ct Scan Referral Form

A CT scan referral form records a clinician’s request for a computed tomography examination. It collects patient information, the requested examination, and the clinical reason for the referral. The receiving imaging service uses those details to review the request and determine the next steps.

An incomplete referral can lead to follow-up calls before the imaging team has enough information to review it. A dedicated form prompts clinicians to include the clinical question, relevant history, and contact details together. It also helps staff identify missing information before the request is submitted.

Build the form around the receiving imaging service’s requirements:

• Patient name, date of birth, and contact details
• Relevant patient identifiers
• Requested examination or body area
• Clinical question and relevant history
• Requested urgency and the reason for it
• Relevant previous imaging or reports
• Required screening information
• Referring clinician’s details, referral date, and required authorization

Have the receiving service review the fields before use, and confirm that the submission process meets your organization’s privacy and security requirements.

Keep patient and referrer details separate, and give the clinical question its own clearly labeled field. Use conditional questions for information required only for certain requests. Explain which supporting records to attach and provide a direct contact field so the imaging team can resolve questions efficiently.

Not automatically. The form submits a referral for review; appointment scheduling depends on the receiving service’s process. Use the confirmation message to explain what happens next, who will contact the patient, and how the referring clinician will be notified if more information is needed. Include only preparation instructions supplied by the imaging service.