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Diagnostic imaging request form

Request an X-ray or ultrasound at Circle Care Clinic. Complete the form below and our radiology team will be in touch to arrange your appointment — or download the printable version to share with a referrer.

Prefer a printable form?

Download the radiology request form to complete by hand or share with a referrer.

Download radiology form

Patient details

Referral details

Clinical history

Examination requested

X-Ray

Chest
Other:
Spine & Pelvis
Other:
Head & Neck
Body part / area of interest
Abdomen
Other:
Upper Extremity
Shoulder
Humerus
Scapula
Elbow
Clavicle
Forearm
Hand
Wrist
AC Joints
Other:
Lower Extremity
Hip
Ankle
Femur
Foot
Knee
Tibia Fibula
Long Leg
Other:

Ultrasound

Priority
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