Notre Dame IMAGING REQUEST

Hospital ELECTIVE STAT PORTABLE

AND SCHOOL OF
MIDWIFERY Cotabato City Name:
_____________________________________________________________
(Surname (Given Name) (Middle Name)

Address:

Date: Age: Gender:

Out-Patient In-Patient Room: Birthday:

DIAGNOSTIC PROCEDURE
X-RAY ULTRASOUND Type of Examination:

CT SCAN 2D ECHO

Creatinine: Pedia
Adult
Height: _____
Weight: _____

CLINICAL DIAGNOSIS:
 _______________________ _______________________ _______________________
Requesting Physician Staff On Duty Radiologic Technologist

Scheduled Case No: Note: All blanks must be properly filled up.
Time: Request must be sent prior to the
examination.

FOR SIMULATION USE ONLY