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Scheduling Conservation Scheduling: (512) 3241199 Fax: (512) 3800552 Sedation Scheduling: (512) 3240140 Fax: (512) 3240733 IMAGING SERVICES REQUEST FORM Today's Date: Today's Time: Patient's Name:
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How to fill out Dell Children's Medical Center:

01
Start by collecting all necessary personal and medical information. This can include the patient's full name, date of birth, address, contact details, and insurance information.
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Next, identify the reason for the visit to Dell Children's Medical Center. If the patient is being referred by another healthcare provider, make sure to have the necessary referral documents.
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When filling out the medical history section, provide accurate and complete information about any past or current medical conditions, medications, allergies, surgical history, and family medical history.
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In the consent and authorization section, read and understand the terms and conditions before signing. This may involve giving consent for medical treatments, financial responsibilities, and the release of medical records.
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If applicable, complete any additional forms specific to the services or departments the patient will be using at Dell Children's Medical Center, such as radiology, laboratory, or surgery.
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Double-check all entries and ensure they are legible and accurate. If you have any questions or need assistance, don't hesitate to ask the staff at the medical center for help.

Who needs Dell Children's Medical Center?

01
Children who require specialized medical care and treatment.
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Parents or guardians of children in need of medical assistance.
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Referring healthcare providers who are seeking specialized pediatric care for their patients.
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Dell Children's Medical Center is a pediatric hospital located in Austin, Texas.
Medical professionals and healthcare providers who treat pediatric patients at Dell Children's Medical Center may be required to file reports related to patient care.
To fill out Dell Children's Medical Center reports, healthcare providers must provide accurate and detailed information about the care provided to pediatric patients.
The purpose of Dell Children's Medical Center is to provide specialized medical care to pediatric patients in the Austin area.
Information such as patient demographics, medical diagnoses, treatments, and outcomes may need to be reported on Dell Children's Medical Center forms.
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