Lab and radiology order form templates
Two one-page forms on your letterhead. The lab order groups common tests so a doctor ticks rather than writes; the radiology order asks the clinical question and the safety checks before the patient leaves.
Download
- Word · English.docx · 39 KB
- PDF · English.pdf · 257 KB
- Word · Arabic.docx · 39 KB
- PDF · Arabic.pdf · 113 KB
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Rather fill it in on screen? Lab and radiology request
What is on the pages
| Lab order | Patient details, clinical notes and provisional diagnosis, then tests grouped under haematology, chemistry, hormones, vitamins and minerals, infection and immunity, urine and stool, with free lines for anything else. |
|---|---|
| Lab details | Fasting required, sample collected at the clinic, priority (routine, soon, urgent) and where to send the results: the patient’s WhatsApp, email or the clinic. |
| Radiology order | Modality (X-ray, ultrasound, CT, MRI, mammogram, DEXA), region and views, side and contrast. |
| Radiology safety check | Possible pregnancy and first day of last period, contrast allergy, kidney function when contrast is planned, and pacemaker, implants or metal. |
| The question and the history | The clinical question in the doctor’s words, previous imaging with date and place, priority, results destination, signature and stamp. |
How to use it
Match your providers
Open the Word file and add or remove tests so the list matches what your lab offers.
Add your letterhead
Put your logo and clinic details in the header of each form.
Tick and write the question
Tick the tests or the modality, then write what you want the result to answer.
Keep a copy
Give the original to the patient or the provider and keep a copy in the patient’s file until the result arrives.
Who it is for
Family medicine, internal medicine, gynaecology, orthopaedics and any clinic that sends patients to an outside laboratory or imaging centre. The Arabic file runs right to left; the English file is the same two forms in English.
Questions
Can I change the list of tests?
Yes. The Word file is editable: rename groups, add the panels your lab offers and remove what you never order.
Why is there a clinical question on the radiology form?
The radiologist reports better when they know what you are looking for. A clear question gets a clearer answer.
Why ask about pregnancy and metal?
Some examinations are not done, or are done differently, in pregnancy or with implants. Asking at the clinic saves a wasted trip.
Are the two forms separate?
Yes. Each form is one page with its own letterhead, so you can print only the one you need.
Orders tracked until the result is back
In Medicolize the order is raised from the visit, carries a due date and a status, and the result is attached to the visit that asked for it. Thirty minutes on your own clinic.