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(Place Patient Identification Sticker Here)Methodist University Hospital Ultrasound Department Phone: 9015167129 Fax: 9015162132Contrast Ultrasound Request Form Patient Name ___DOB ___ MRN ___Date/Time
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How to fill out contrast ultrasound request form
How to fill out contrast ultrasound request form
01
Obtain the contrast ultrasound request form from the healthcare provider or imaging center.
02
Fill in the patient's personal information such as name, date of birth, and contact details.
03
Provide details of the referring healthcare provider including name, phone number, and address.
04
Indicate the reason for the contrast ultrasound exam and any specific areas of concern.
05
Include relevant medical history and any allergies to contrast agents.
06
Sign and date the form to confirm accuracy and consent.
07
Submit the completed contrast ultrasound request form to the imaging center or healthcare provider.
Who needs contrast ultrasound request form?
01
Patients who have been referred for a contrast ultrasound exam.
02
Healthcare providers who are requesting the contrast ultrasound exam for their patients.
03
Imaging centers that require the completed form for scheduling and performing the exam.
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What is contrast ultrasound request form?
Contrast ultrasound request form is a medical form used to request a contrast-enhanced ultrasound procedure.
Who is required to file contrast ultrasound request form?
Healthcare professionals, such as physicians or radiologists, are required to file contrast ultrasound request form.
How to fill out contrast ultrasound request form?
The form must be filled out with patient information, medical history, reason for procedure, and any relevant clinical information.
What is the purpose of contrast ultrasound request form?
The purpose of the form is to provide necessary information for healthcare providers to perform a contrast-enhanced ultrasound procedure.
What information must be reported on contrast ultrasound request form?
Patient demographics, medical history, reason for procedure, relevant clinical information, and any contraindications to the contrast agent.
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