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Radiology
Laboratory
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Request for Radiological Investigation
Request for Radiological Investigation
Patient Information
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Date of Request
Time
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Date Required (Results)
Health Insurance
No
Yes
Full Names
*
Full Names
First
First
Last
Last
Age
Gender
*
Male
Female
Patient File Number
Email
Phone Number
Brief Clinical Details (DDx)
Patient Weight
(If Patient is Obese)
Creatinine Result
(If Contrast is Required)
Allergies
Indicate NONE if no known allergies
Special Conditions
*
NONE
Pregnant
Diabetic
Hypertensive
Orthopaedic Implants
IUCD
Needs Mobility Aid
Investigations
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More input fields will appear below as you fill out the ones above
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Nuclear
Cardiology
Obs/Gynae
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
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Doctor's Signature
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