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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name, birthdate, and address in the designated fields. Ensure accuracy for effective communication.
Fill in the contact information for both home and work phones, along with the appointment date and time to confirm scheduling.
In the PHYSICIAN section, print the physician's name, and provide their signature along with phone and fax numbers for follow-up.
Select the appropriate radiology procedures from the list provided. Indicate left (L) or right (R) as necessary for each examination.
Complete any additional information or comments that may be relevant to the patient's examination needs.

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