Outpatient Order Forms
In an effort to ensure that our physician community is able to easily access the information and documents they need in order to serve their patients, Randolph Health has enabled the use of electronic outpatient order forms. There is a separate form for each type of service that needs to be ordered.
Please create a shortcut to this specific web page on your desktop or mark it as a bookmark or favorite so the forms can be easily accessed.
When needed, print the form, complete it and fax the order to the appropriate fax number listed on the form when you schedule the test.
If you need to schedule Imaging, you may call 336-328-3333, select option 7. Fax orders for Imaging to 336-328-4415.
January 1, 2020 a Medicare mandate regarding advanced imaging test (CT, MRI/MRA, NM, PET) begins. This mandate requires additional information to be provided for Medicare B patients. Click here for additional information.
Forms available:
- Cardiac Rehabilitation
- COVID-19 Informed Consent
- COVID-19 Informed Consent (Spanish)
- CT Lung Screening
- CT scan
- Diabetes self-management program
- Diagnostic x-ray
- EKG, ECHO, respiratory procedures
- Endoscopy
- Evenity
- FaithHealthNC
- Fluoroscopy injections
- Fluoroscopy
- Gestational diabetes
- Home Health Referral Form
- Interventional radiology
- Labs
- Mammograms
- Medical nutrition therapy
- MRI
- MRI patient referral
- Nuclear Medicine
- Outpatient physical therapy (Ortho/Sports/Deep River)
- Outpatient rehab services (Randolph Health PT/OT/ST)
- Prolia
- Pulmonary rehabilitation
- Reclast
- Spinal injection
- Ultrasound
- Vascular ultrasound
- Wound Care
(Other tests include echocardiography, EKG/EEG, respiratory therapy, sleep studies, special procedures, physical therapy, hand rehab, speech therapy and cardiopulmonary.)