radiological series requested - life...

RRAA DD II OO LL OO GG YY DDEE PP AA RR TT MM EE NN TTRadiology Request Form – Outside Referrals

1415 Barclay Circle n Marietta, GA 30060 n (770) 426-2766 n fax (770) 426-2998 n www.LIFE.edu

Patient’s Legal Name: Request Date:

Address: Phone:

City/State/Zip: Cell:

Date of Birth: Gender: M F Height: Weight:

Chief Complaint: Onset Date: Significant symptoms

and/or clinical findings:Reason for X-rays:

-------------- Spinal Series -------------- ---- Upper Extremity Series ---- ---- Lower Extremity Series ----

Cervical 3v (AP, APOM, Lat) AC Joint 4v R L Hip 3v R LAdd: Obliques Flex/Ext Shoulder 3v R L Knee 4v R L

Toggle 4v (AP, APOM, Lat, Vertex) Elbow 4v R L Ankle 3v R LAdd: Nasium Wrist 4v R L Foot 3v R LPost: Nasium Vertex Hand 3v R L Calcanius 2v R L

Thoracic 2v (AP, Lat) Finger 3v R L Toe 3v R L

Lumbar 3v (AP, Lat, Lat-L5 spot)Add: Obliques Flex/Ext ---- Other Series ------------------------------------------------------------------

Full Spine (14x36) Chest 2v (PA, Lat)

Scoliosis 3v (PA 14x36, Lat T&L) Ribs 3v R LPost: Scoliosis 1v (PA 14x36)

Pelvis 1v Long Bone 2v (AP, Lat) Specify Area:

Sacrum 2v (AP, Lat)

Rad

iolo

gica

l Ser

ies

Req

uest

ed

Coccyx 2v

Additional Views Specify:

Referring Doctor Name: Please complete patient history on next page.

Address: Phone:

City/State/Zip: Fax:

Doctor’s Signature:

Delivery Method (choose one): Send copy of films with patient (copy is on a disk) *Final Report to be faxed/mailed*Mail copy of films with final report (copy is on a disk)

Doctor will pick up disk and final report

Life Clinics Use OnlyFile # _______________ Intern Name ____________________________________ Intern # _________ Qtr: ____

PREGNANCY RELEASE (REQUIRED – FEMALE PATIENTS BETWEEN THE AGES OF 12 AND 65)

This is to certify to the best of my knowledge, I am NOT PREGNANT and that Life University College of Chiropractic Clinics has my permission to take X-Rays.First day of last menstrual period: ______________ Patient Signature:__________________________________________

Date signed: _________________________ Witness signature: _________________________________________

http://www.LIFE.edudrearleyNoteAccepted set by drearley

drearleyNoteUnmarked set by drearley

drearleyNoteUnmarked set by drearley

drearleyNoteAccepted set by drearley

drearleyNoteCompleted set by drearley

drearleyNoteCompleted set by drearley

Patient History

Patient’s Name: Request Date:

Select "No" or "Yes" for each question below. If yes, provide full details, including nature and duration of illness and dates.

Cancer or tumor of any type? No Yes Details:

Results of treatment:

Kidney, liver or gallbladder disease, including stones? No Yes Details:

Arthritis, gout or joint pains (e.g. shoulder, hand, knee, ankle, hip) or any other disorder of joints or bones? No Yes Details:

Any history of trauma, broken bones or sprains? No Yes Details:

Any neck, or back complaint, back injury or back pain? No Yes Details:

High blood pressure, rheumatic fever, heart murmur or any heart complaint? No Yes Details:

Asthma, tuberculosis, bronchitis, emphysema or any other lung illness? No Yes Details:

Any blood disorder, AIDS, HIV+, hepatitis? No Yes Details:

Any hospitalizations other than surgery? No Yes Details:

Any surgeries, inpatient or outpatient? No Yes Details:

Any tobacco use? If patient smokes or smoked cigarettes; how long and how many packs per day? No Yes Details:

Any imaging (e.g. x-ray, MRI, CT)? No Yes Details:

Results:May we request radiologist report? No Yes Location:

Any medical devices/implants (e.g. pacemaker, insulin pumps, breathing devices, shunts)? No Yes Details:

Any history of endocrine problems (diabetes, pituitary tumors / disorders)? No Yes Details:

LIFE CLINICS USE ONLY View cm mAs kVp FFD Remarks View cm mAs kVp FFD Remarks

X-RAY COMPLETED Study: _______________________________ Date: __________________ Technologist: ___________________

This file was generated by 'Microsoft® Word 2003(11.0.8237.0) - CIB pdf brewer 2.5.26'.

Please use the current version of CIB pdf brewer for opening.The setup can be downloaded from our website free of charge: www.cib.de

Radiology Outside Request Online CIB.rtf

Radiology Outside Request Online CIB.xml

Readme.txt

http://www.cib.de

Radiology Department

Radiology Request Form – Outside Referrals


Patient’s Legal Name:

Request Date:

Address:

Phone:

City/State/Zip:

GA

Cell:

Date of Birth:

Gender:

M F

Height:

Weight:

Chief Complaint:

Onset Date:

Significant symptoms and/or clinical findings:

Reason for X-rays:

Radiological Series Requested

-------------- Spinal Series --------------

---- Upper Extremity Series ----

---- Lower Extremity Series ----

Cervical 3v (AP, APOM, Lat)

AC Joint

4v

R

L

Hip

3v

R

L

Add: Obliques Flex/Ext

Shoulder

3v

R

L

Knee

4v

R

L

Toggle 4v (AP, APOM, Lat, Vertex)

Elbow

4v

R

L

Ankle

3v

R

L

Add: Nasium

Wrist

4v

R

L

Foot

3v

R

L

Post: Nasium Vertex

Hand

3v

R

L

Calcanius

2v

R

L

Thoracic 2v (AP, Lat)

Finger

3v

R

L

Toe

3v

R

L

Lumbar 3v (AP, Lat, Lat-L5 spot)


---- Other Series ------------------------------------------------------------------

Full Spine (14x36)

Chest

2v

(PA, Lat)

Scoliosis 3v (PA 14x36, Lat T&L)

Ribs

3v

R

L

Post: Scoliosis 1v (PA 14x36)

Pelvis 1v

Long Bone 2v (AP, Lat) Specify Area:

Sacrum 2v (AP, Lat)


Coccyx 2v

Referring Doctor Name:

Please complete patient history on next page.

Address:

Phone:

City/State/Zip:

GA

Fax:


Delivery Method (choose one): Send copy of films with patient (copy is on a disk) *Final Report to be faxed/mailed*

Mail copy of films with final report (copy is on a disk)


Life Clinics Use Only

File # _______________ Intern Name ____________________________________ Intern # _________ Qtr: ____

Pregnancy Release (Required – Female Patients Between the Ages of 12 and 65)

This is to certify to the best of my knowledge, I am NOT PREGNANT and that Life University College of Chiropractic Clinics has my permission to take X-Rays.

First day of last menstrual period: ______________Patient Signature:__________________________________________

Date signed: _________________________Witness signature: _________________________________________




Patient History

Patient’s Name:

Request Date:


Cancer or tumor of any type?

No

Yes

Details:


Kidney, liver or gallbladder disease, including stones?

No

Yes

Details:

Arthritis, gout or joint pains (e.g. shoulder, hand, knee, ankle, hip) or any other disorder of joints or bones?

No

Yes

Details:

Any history of trauma, broken bones or sprains?

No

Yes

Details:

Any neck, or back complaint, back injury or back pain?

No

Yes

Details:

High blood pressure, rheumatic fever, heart murmur or any heart complaint?

No

Yes

Details:

Asthma, tuberculosis, bronchitis, emphysema or any other lung illness?

No

Yes

Details:

Any blood disorder, AIDS, HIV+, hepatitis?

No

Yes

Details:

Any hospitalizations other than surgery?

No

Yes

Details:

Any surgeries, inpatient or outpatient?

No

Yes

Details:

Any tobacco use? If patient smokes or smoked cigarettes; how long and how many packs per day?

No

Yes

Details:

Any imaging (e.g. x-ray, MRI, CT)?

No

Yes

Details:

Results:

May we request radiologist report?

No

Yes

Location:

Any medical devices/implants (e.g. pacemaker, insulin pumps, breathing devices, shunts)?

No

Yes

Details:

Any history of endocrine problems (diabetes, pituitary tumors / disorders)?

No

Yes

Details:

Radiology Outside Request Online CIB.rtf

100 100 1 0 0 0 0 0 75 600 1 0 0 0 0 0 14 0 0 0 0 0 0 0 0 0 0 Silkscreen 0 0 259 0 2 4 0 C:\Temp\~ERadiology Outside Request Online CIB.pdf _e 0 0 iexplore.exe %s 0 0 1 1 0 100 0 0 ~EC8.tmp 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 15 0 -16777216 0 -16777216 1 0 0 -16777216 0 -16777216 0 -16777216 Patient’s Legal Name: Scott Earley 32 1 3939 10751 19510 18157 18855 29827 26685 -23095 {STYLE:normal;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:heading 1;1;{FONT:Arial;16;Bold;0.0.0}};{STYLE:heading 2;2;{FONT:Arial;14;Bold;Italic;0.0.0}};{STYLE:heading 3;3;{FONT:Arial;13;Bold;0.0.0}};{STYLE:heading 4;4;{FONT:Times New Roman;14;Bold;0.0.0}};{STYLE:heading 5;5;{FONT:Times New Roman;13;Bold;Italic;0.0.0}};{STYLE:heading 6;6;{FONT:Times New Roman;11;Bold;0.0.0}};{STYLE:heading 7;7;{FONT:Times New Roman;12;0.0.0}};{STYLE:heading 8;8;{FONT:Times New Roman;12;Italic;0.0.0}};{STYLE:heading 9;9;{FONT:Arial;11;0.0.0}};{STYLE:index 1;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 3;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 4;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 5;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 6;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 7;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 8;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 9;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 1;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 3;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 4;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 5;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 6;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 7;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 8;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 9;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Normal Indent;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:footnote text;1;{FONT:Times New Roman;10;0.0.0}};{STYLE:comment text;1;{FONT:Times New Roman;10;0.0.0}};{STYLE:header;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:footer;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index heading;1;{FONT:Arial;12;Bold;0.0.0}};{STYLE:caption;1;{FONT:Times New Roman;10;Bold;0.0.0}};{STYLE:table of figures;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:envelope address;1;{FONT:Arial;12;0.0.0}};{STYLE:envelope return;1;{FONT:Arial;10;0.0.0}};{STYLE:endnote text;1;{FONT:Times New Roman;10;0.0.0}};{STYLE:table of authorities;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:macro;1;{FONT:Courier New;10;0.0.0}};{STYLE:toa heading;1;{FONT:Arial;12;Bold;0.0.0}};{STYLE:List;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Bullet;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Number;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List 3;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List 4;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List 5;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Bullet 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Bullet 3;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Bullet 4;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Bullet 5;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Number 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Number 3;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Number 4;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Number 5;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Title;1;{FONT:Arial;16;Bold;0.0.0}};{STYLE:Closing;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Signature;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text Indent;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Continue;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Continue 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Continue 3;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Continue 4;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Continue 5;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Message Header;1;{FONT:Arial;12;0.0.0}};{STYLE:Subtitle;1;{FONT:Arial;12;0.0.0}};{STYLE:Salutation;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Date;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text First Indent;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text First Indent 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Note Heading;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text 3;1;{FONT:Times New Roman;8;0.0.0}};{STYLE:Body Text Indent 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text Indent 3;1;{FONT:Times New Roman;8;0.0.0}};{STYLE:Block Text;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Document Map;1;{FONT:Tahoma;10;0.0.0}};{STYLE:Plain Text;1;{FONT:Courier New;10;0.0.0}};{STYLE:E-mail Signature;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:z-Top of Form;1;{FONT:Arial;8;0.0.0}};{STYLE:z-Bottom of Form;1;{FONT:Arial;8;0.0.0}};{STYLE:HTML Normal;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:HTML Address;1;{FONT:Times New Roman;12;Italic;0.0.0}};{STYLE:HTML Preformatted;1;{FONT:Courier New;10;0.0.0}};

Radiology Outside Request Online CIB.xml



Readme.txt




Patient’s Legal Name:

Request Date:

Address:

Phone:

City/State/Zip:

GA

Cell:

Date of Birth:

Gender:

M F

Height:

Weight:

Chief Complaint:

Onset Date:

Significant symptoms and/or clinical findings:

Reason for X-rays:

Radiological Series Requested

-------------- Spinal Series --------------

---- Upper Extremity Series ----

---- Lower Extremity Series ----

Cervical 3v (AP, APOM, Lat)

AC Joint

4v

R

L

Hip

3v

R

L


Shoulder

3v

R

L

Knee

4v

R

L

Toggle 4v (AP, APOM, Lat, Vertex)

Elbow

4v

R

L

Ankle

3v

R

L

Add: Nasium

Wrist

4v

R

L

Foot

3v

R

L

Post: Nasium Vertex

Hand

3v

R

L

Calcanius

2v

R

L

Thoracic 2v (AP, Lat)

Finger

3v

R

L

Toe

3v

R

L

Lumbar 3v (AP, Lat, Lat-L5 spot)


---- Other Series ------------------------------------------------------------------

Full Spine (14x36)

Chest

2v

(PA, Lat)

Scoliosis 3v (PA 14x36, Lat T&L)

Ribs

3v

R

L

Post: Scoliosis 1v (PA 14x36)

Pelvis 1v

Long Bone 2v (AP, Lat) Specify Area:

Sacrum 2v (AP, Lat)


Coccyx 2v

Referring Doctor Name:

Please complete patient history on next page.

Address:

Phone:

City/State/Zip:

GA

Fax:


Delivery Method (choose one): Send copy of films with patient (copy is on a disk) *Final Report to be faxed/mailed*

Mail copy of films with final report (copy is on a disk)


Life Clinics Use Only

File # _______________ Intern Name ____________________________________ Intern # _________ Qtr: ____

Pregnancy Release (Required – Female Patients Between the Ages of 12 and 65)

This is to certify to the best of my knowledge, I am NOT PREGNANT and that Life University College of Chiropractic Clinics has my permission to take X-Rays.

First day of last menstrual period: ______________Patient Signature:__________________________________________

Date signed: _________________________Witness signature: _________________________________________




Patient History

Patient’s Name:

Request Date:


Cancer or tumor of any type?

No

Yes

Details:


Kidney, liver or gallbladder disease, including stones?

No

Yes

Details:

Arthritis, gout or joint pains (e.g. shoulder, hand, knee, ankle, hip) or any other disorder of joints or bones?

No

Yes

Details:

Any history of trauma, broken bones or sprains?

No

Yes

Details:

Any neck, or back complaint, back injury or back pain?

No

Yes

Details:

High blood pressure, rheumatic fever, heart murmur or any heart complaint?

No

Yes

Details:

Asthma, tuberculosis, bronchitis, emphysema or any other lung illness?

No

Yes

Details:

Any blood disorder, AIDS, HIV+, hepatitis?

No

Yes

Details:

Any hospitalizations other than surgery?

No

Yes

Details:

Any surgeries, inpatient or outpatient?

No

Yes

Details:

Any tobacco use? If patient smokes or smoked cigarettes; how long and how many packs per day?

No

Yes

Details:

Any imaging (e.g. x-ray, MRI, CT)?

No

Yes

Details:

Results:

May we request radiologist report?

No

Yes

Location:

Any medical devices/implants (e.g. pacemaker, insulin pumps, breathing devices, shunts)?

No

Yes

Details:

Any history of endocrine problems (diabetes, pituitary tumors / disorders)?

No

Yes

Details:

100 100 1 0 0 0 0 0 75 600 1 0 0 0 0 0 14 0 0 0 0 0 0 0 0 0 0 Silkscreen 0 0 259 0 2 4 0 C:\Temp\~ERadiology Outside Request Online CIB.pdf _e 0 0 iexplore.exe %s 0 0 1 1 0 100 0 0 ~EC8.tmp 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 15 0 -16777216 0 -16777216 1 0 0 -16777216 0 -16777216 0 -16777216 Patient’s Legal Name: Scott Earley 32 1 3939 10751 19510 18157 18855 29827 26685 -23095 {STYLE:normal;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:heading 1;1;{FONT:Arial;16;Bold;0.0.0}};{STYLE:heading 2;2;{FONT:Arial;14;Bold;Italic;0.0.0}};{STYLE:heading 3;3;{FONT:Arial;13;Bold;0.0.0}};{STYLE:heading 4;4;{FONT:Times New Roman;14;Bold;0.0.0}};{STYLE:heading 5;5;{FONT:Times New Roman;13;Bold;Italic;0.0.0}};{STYLE:heading 6;6;{FONT:Times New Roman;11;Bold;0.0.0}};{STYLE:heading 7;7;{FONT:Times New Roman;12;0.0.0}};{STYLE:heading 8;8;{FONT:Times New Roman;12;Italic;0.0.0}};{STYLE:heading 9;9;{FONT:Arial;11;0.0.0}};{STYLE:index 1;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 3;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 4;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 5;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 6;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 7;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 8;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index 9;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 1;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 3;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 4;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 5;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 6;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 7;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 8;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:toc 9;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Normal Indent;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:footnote text;1;{FONT:Times New Roman;10;0.0.0}};{STYLE:comment text;1;{FONT:Times New Roman;10;0.0.0}};{STYLE:header;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:footer;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:index heading;1;{FONT:Arial;12;Bold;0.0.0}};{STYLE:caption;1;{FONT:Times New Roman;10;Bold;0.0.0}};{STYLE:table of figures;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:envelope address;1;{FONT:Arial;12;0.0.0}};{STYLE:envelope return;1;{FONT:Arial;10;0.0.0}};{STYLE:endnote text;1;{FONT:Times New Roman;10;0.0.0}};{STYLE:table of authorities;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:macro;1;{FONT:Courier New;10;0.0.0}};{STYLE:toa heading;1;{FONT:Arial;12;Bold;0.0.0}};{STYLE:List;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Bullet;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Number;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List 3;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List 4;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List 5;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Bullet 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Bullet 3;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Bullet 4;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Bullet 5;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Number 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Number 3;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Number 4;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Number 5;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Title;1;{FONT:Arial;16;Bold;0.0.0}};{STYLE:Closing;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Signature;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text Indent;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Continue;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Continue 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Continue 3;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Continue 4;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:List Continue 5;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Message Header;1;{FONT:Arial;12;0.0.0}};{STYLE:Subtitle;1;{FONT:Arial;12;0.0.0}};{STYLE:Salutation;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Date;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text First Indent;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text First Indent 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Note Heading;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text 3;1;{FONT:Times New Roman;8;0.0.0}};{STYLE:Body Text Indent 2;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Body Text Indent 3;1;{FONT:Times New Roman;8;0.0.0}};{STYLE:Block Text;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:Document Map;1;{FONT:Tahoma;10;0.0.0}};{STYLE:Plain Text;1;{FONT:Courier New;10;0.0.0}};{STYLE:E-mail Signature;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:z-Top of Form;1;{FONT:Arial;8;0.0.0}};{STYLE:z-Bottom of Form;1;{FONT:Arial;8;0.0.0}};{STYLE:HTML Normal;1;{FONT:Times New Roman;12;0.0.0}};{STYLE:HTML Address;1;{FONT:Times New Roman;12;Italic;0.0.0}};{STYLE:HTML Preformatted;1;{FONT:Courier New;10;0.0.0}};



Address: PtPhone: PtCity: PtState: GAPtZip: PtCell: PtDOB: PtHeight: PtWeight: ChiefComplaint: Onset: Findings1: Reason: ACJ: OffACR: OffACL: OffHip: OffHipR: OffHipL: OffCervOb: OffCervFlex: OffShoulder: OffShoulderR: OffShoulderL: OffKnee: OffKneeR: OffKneeL: OffElbow: OffElbowR: OffElbowL: OffAnkle: OffAnkleR: OffAnkleL: OffTogNas: OffWrist: OffWristR: OffWristL: OffFoot: OffFootR: OffFootL: OffTogPostNas: OffTogPostVer: OffHand: OffHandR: OffHandL: OffCalcanius: OffCalcaniusR: OffCalcaniusL: OffFinger: OffFingerR: OffFingerL: OffToe: OffToeR: OffToeL: OffLumbOb: OffLumbFlex: OffChest: OffCheck5: OffRibs: OffRibsR: OffRibsL: OffScoliosisPost: OffCheck6: OffLongBone: OffLongSpecify: Check7: OffAdditional: OffAdditionalSpecify: Check8: OffDoctor: DocAddress: DocPhone: DocCity: DocState: GADocZip: DocFax: PtName: ReqDate: Q1D: Q1R: Q2D: Q3D: Q4D: Q5D: Q6D: Q7D: Q8D: Q9D: Q10D: Q11D: Q12D: Q12R: RRptLoc: Q13D: Q14D: Gender: OffReport: OffQ1: OffQ14: OffQ13: OffQ12: OffQ11: OffQ10: OffQ9: OffQ8: OffQ7: OffQ6: OffQ5: OffQ4: OffQ3: OffQ2: OffQ12b: OffCerv: OffCheck1: OffCheck2: OffCheck3: OffCheck4: OffButton1:

radiological series requested - life...

Documents