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Imaging Request Form (PDF) - Centre for Health - centreforhealth org 2025

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165 votes

The document is an Imaging Request Form used to collect patient information and details for imaging examinations such as X-Ray, Ultrasound, or MRI. It includes sections for patient demographics, examination requests, clinical details, referrer’s declaration, consent from the patient, and billing information. The form ensures compliance with medical regulations and requires signatures from both the referrer and the patient.

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Versions	Form popularity	Fillable & printable
2011	4.8 Satisfied (165 Votes)

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