Radiology No-Show Report Form
Report and track missed radiology appointments to support follow-up and rescheduling.
Patient Name
*
First Name
Last Name
Date of Scheduled Appointment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Radiology Modality
*
Please Select
X-ray
CT
MRI
Ultrasound
Nuclear Medicine
Other
Appointment Location
Reason for No-Show
*
Please Select
Forgot appointment
Transportation issues
Scheduling conflict
Illness
Unable to contact patient
Other
Follow-Up Preference
*
Reschedule appointment
Contact patient for follow-up
No follow-up required
Preferred Contact Method for Follow-Up
Phone
Email
No contact needed
Additional Notes
Staff Reporting
Submit Report
Should be Empty: