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YOUR LOGO HERE EXAM REQUISITION RAY CT MRI US NUCLEAR MEDICINE PET×CT DEXA MRA MAMMOGRAPHY ORGAN SYSTEM’S) TO BE EXAMINED Today's Date: Patient Name: Date of Birth: Patient Phone: (Day) (Evening)
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Exam requisition is a form used to request a radiology exam such as an X-ray, MRI, or CT scan.
Patients or their healthcare providers are required to file exam requisition.
To fill out exam requisition, one must provide patient information, exam requested, reason for exam, and any relevant medical history.
The purpose of exam requisition is to ensure the correct exam is performed on the right patient for the appropriate medical reasons.
Information such as patient name, date of birth, exam requested, referring physician, and relevant medical history must be reported on exam requisition.
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