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Umass radiology requisition form

Umass radiology requisition form 2025

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The document is a request form for consultation, imaging, and interventional procedures related to cardiovascular conditions at Massachusetts General Hospital. It outlines various diagnoses and symptoms, provides options for imaging requests (such as ultrasound Doppler, CTA, and MRA), and explains the process for scheduling exams or consultations. The form emphasizes coordination to minimize patient inconvenience and includes contact information for further inquiries.

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Click ‘Get Form’ to open the umass radiology requisition form in the editor.
Begin by entering the patient's name and MGH Unit number at the top of the form. This information is crucial for identifying the patient.
In the 'Physician' section, print your name clearly along with your phone number. Ensure that you also provide your MD Provider number for verification.
Fill in the date of request and specify the diagnosis or symptoms in the designated field. This helps in understanding the patient's condition.
Select all applicable imaging requests by checking the appropriate boxes under each category, such as 'Cerebrovascular disease' or 'Peripheral arterial occlusive disease'.
If a consultation is needed, check the corresponding box and provide any additional comments that may assist in scheduling.
Review all entered information for accuracy before saving or sending your completed form.

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