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Experience, Excellence. #201 1032 Austin Ave. Coquitlam, BC V3K 3P3IMAGING REFERRAL FORMinfo@TricitiesDental.ca (604)9398467Referring Doctor Info: Dr. Name ___Referring Office Name: ___Office Address:
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How to fill out imaging referral form
How to fill out imaging referral form
01
Obtain the imaging referral form from the healthcare provider or facility.
02
Fill out the patient's personal information like name, date of birth, and contact details.
03
Specify the type of imaging needed (e.g. X-ray, MRI, CT scan).
04
Provide the reason for the referral and any relevant medical history.
05
Include the healthcare provider's information and signature.
06
Submit the completed imaging referral form to the imaging facility.
Who needs imaging referral form?
01
Patients who require medical imaging tests such as X-rays, MRI, or CT scans.
02
Healthcare providers who need to refer patients for imaging services.
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What is imaging referral form?
Imaging referral form is a document used to request imaging services such as X-rays, MRIs, or CT scans.
Who is required to file imaging referral form?
Healthcare providers or physicians are required to file imaging referral forms for their patients.
How to fill out imaging referral form?
The form should be completed with the patient's information, reason for the imaging request, and any relevant medical history.
What is the purpose of imaging referral form?
The purpose of the imaging referral form is to authorize and document the need for imaging services.
What information must be reported on imaging referral form?
Patient's name, date of birth, reason for imaging request, referring physician's information, and any relevant medical history.
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