RADIOLOGY REPORT ADDENDUM REQUEST FORM
Please complete this form to request an addendum to your radiology report. An addendum is the text added at the beginning of a previously finalized radiology report to correct or expand on an original statement. Please be advised that an addendum request can take anywhere from 2-4 weeks for completion. You will be notified if we cannot complete your request. Report changes are at the discretion of the radiologist.
First Name
*
Last Name
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone
*
-
Area Code
Phone Number
May we leave a voicemail if prompted?
*
Please Select
- Select -
Yes
No
Exam Requested
*
Clinician's Name
*
Date(s) of Service
Reason for Addendum Request
Spelling Error
Dates Incorrect
Verbiage Changes
Other
If Other, please include detailed information here.
Submit
Should be Empty: