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HERMITAGE MEDICAL CLINIC
RADIOLOGY DEPARTMENT
PH 01 6459042/9043
LMP DATE:Name:
Address:Is there any possibility this patient is
pregnant No:Yes
Patients Signature:DOB:MF(Affix label here please)
Outpatient
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How to fill out hermitage clinic radiology referral
How to fill out hermitage clinic radiology referral
01
Step 1: Obtain a referral form from your healthcare provider.
02
Step 2: Fill out the patient's personal information including name, date of birth, and contact information.
03
Step 3: Provide the reason for the referral and any relevant medical history.
04
Step 4: Make sure all sections of the form are completed accurately and legibly.
05
Step 5: Return the completed referral form to the hermitage clinic radiology department either in person or by fax.
Who needs hermitage clinic radiology referral?
01
Patients who require radiology services such as x-rays, MRIs, or ultrasounds.
02
Healthcare providers who are referring their patients for radiology tests.
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What is hermitage clinic radiology referral?
Hermitage clinic radiology referral is a request made by a healthcare provider to schedule a radiology test or procedure for a patient.
Who is required to file hermitage clinic radiology referral?
Healthcare providers such as doctors, nurse practitioners, or physician assistants are required to file hermitage clinic radiology referral for their patients.
How to fill out hermitage clinic radiology referral?
To fill out hermitage clinic radiology referral, healthcare providers need to provide patient information, reason for the referral, type of radiology test needed, and any relevant medical history.
What is the purpose of hermitage clinic radiology referral?
The purpose of hermitage clinic radiology referral is to ensure that patients receive necessary radiology tests or procedures in a timely manner.
What information must be reported on hermitage clinic radiology referral?
Hermitage clinic radiology referral must include patient's name, date of birth, contact information, reason for referral, type of test needed, referring provider information, and any relevant medical history.
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