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History of intra-orbital fb Intracranial clips Tel. Fax. Pacemaker NO Cochlear implants Signed by referrer. Diabetic on Drugs/Contrast. Any kidney problems Taking anticoagulants/antiplatelet drugs e.g. Aspirin or EGFR result. Examination required DoB. /. / Hospital No X. Address. Daytime Tel. Mobile. Email Females 12-55yrs Clinical indication LMP date. Imaging Request Form Please fax this form to 020 3447 2898 For appointments/enquiries please call 020 3447 2800 170 Tottenham Court Road...
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