Scribd Logo
Upload

Welcome to Scribd!

  • REQUEST SLIP Ultrasound

    Uploaded by

    Polpol Grace
    18 views1 page
    This document contains two identical request slips from Aero Medical and Diagnostic Clinic. The slips include fields for patient name, date, address, age, sex, birthday, and last menstrual period. They list various types of ultrasound examinations that can be requested including biophysical scoring for single or twin pregnancies, examinations of the kidneys, liver, gallbladder, pelvis, prostate, thyroid, soft tissues, and whole abdomen. The slips note the clinic's address, phone number, email, hours of operation from 8 AM to 5 PM Monday to Saturday, and are signed for by the requesting physician.

    Original Description:

    Original Title

    REQUEST SLIP ultrasound

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document contains two identical request slips from Aero Medical and Diagnostic Clinic. The slips include fields for patient name, date, address, age, sex, birthday, and last menstrual period. They list various types of ultrasound examinations that can be requested including biophysical scoring for single or twin pregnancies, examinations of the kidneys, liver, gallbladder, pelvis, prostate, thyroid, soft tissues, and whole abdomen. The slips note the clinic's address, phone number, email, hours of operation from 8 AM to 5 PM Monday to Saturday, and are signed for by the requesting physician.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    18 views1 page

    REQUEST SLIP Ultrasound

    Uploaded by

    Polpol Grace
    This document contains two identical request slips from Aero Medical and Diagnostic Clinic. The slips include fields for patient name, date, address, age, sex, birthday, and last menstrual period. They list various types of ultrasound examinations that can be requested including biophysical scoring for single or twin pregnancies, examinations of the kidneys, liver, gallbladder, pelvis, prostate, thyroid, soft tissues, and whole abdomen. The slips note the clinic's address, phone number, email, hours of operation from 8 AM to 5 PM Monday to Saturday, and are signed for by the requesting physician.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 1

    PREQUEST SLIP REQUEST SLIP

    AERO MEDICAL AND DIAGNOSTIC CLINIC AERO MEDICAL AND DIAGNOSTIC CLINIC
    Crossing Manikling, San Isidro, Davao Oriental Crossing Manikling, San Isidro, Davao Oriental
    Tel: 09274033804 Email: [email protected] Tel: 09274033804 Email: [email protected]

    Name:_____________________ Date:______________ Name:_____________________ Date:______________


    REQUEST SLIP
    Address:___________________Age/Sex:____________ REQUEST SLIP
    Address:___________________Age/Sex:____________
    AERO MEDICAL
    Birthday:__________________ AND DIAGNOSTIC CLINIC
    LMP:_______________ AERO MEDICAL
    Birthday:__________________ ANDLMP:_______________
    DIAGNOSTIC CLINIC
    Crossing Manikling, San Isidro, Davao Oriental Crossing Manikling, San Isidro, Davao Oriental
    ULTRASOUND: ULTRASOUND:
    Tel: 09274033804 Email: [email protected] Tel: 09274033804 Email: [email protected]

    BIOPHYSICAL SCORING (SINGLE) BIOPHYSICAL SCORING (SINGLE)


    Name:_____________________ Date:______________ Name:_____________________ Date:______________
    Address:___________________Age/Sex:____________
    BIOPHYSICAL SCORING (TWIN) Address:___________________Age/Sex:____________
    BIOPHYSICAL SCORING (TWIN)
    Birthday:__________________ LMP:_______________ Birthday:__________________ LMP:_______________
    ULTRASOUND:
    KUB KUB
    ULTRASOUND:
    KUB + PROSTATE/PELVIS KUB + PROSTATE/PELVIS
    BIOPHYSICAL SCORING (SINGLE) BIOPHYSICAL SCORING (SINGLE)
    KUB + PROSTATE/PELVIS (PRE/POST VOID) KUB + PROSTATE/PELVIS (PRE/POST VOID)
    BIOPHYSICAL SCORING (TWIN) BIOPHYSICAL SCORING (TWIN)
    LIVER, GB,HBT LIVER, GB,HBT
    KUB
    PREGNANCY EVALUATION (SINGLE) KUB
    PREGNANCY EVALUATION (SINGLE)
    KUB + PROSTATE/PELVIS KUB + PROSTATE/PELVIS
    PREGNANCY EVALUATION (TWIN) PREGNANCY EVALUATION (TWIN)
    KUB + PROSTATE/PELVIS (PRE/POST VOID) KUB + PROSTATE/PELVIS (PRE/POST VOID)
    THYROID THYROID
    LIVER, GB,HBT LIVER, GB,HBT
    UPPER ABDOMEN UPPER ABDOMEN
    PREGNANCY EVALUATION (SINGLE) PREGNANCY EVALUATION (SINGLE)
    WHOLE ABDOMEN WHOLE ABDOMEN
    PREGNANCY EVALUATION (TWIN) PREGNANCY EVALUATION (TWIN)
    WHOLE ABDOMEN + PROSTATE/PELVIS WHOLE ABDOMEN + PROSTATE/PELVIS
    THYROID THYROID
    SOFT TISSUE SOFT TISSUE
    UPPER ABDOMEN UPPER ABDOMEN
    REQUESTED BY: ____________________________________________ REQUESTED BY:ABDOMEN
    ____________________________________________
    WHOLE ABDOMEN
    “Above and beyond services” WHOLE
    “Above and beyond services”
    Clinic Hours: 8:00 AM to 5:00 PM Clinic Hours:+8:00 AM to 5:00 PM
    WHOLE ABDOMEN + PROSTATE/PELVIS
    (Monday to Saturday) WHOLE ABDOMEN PROSTATE/PELVIS
    (Monday to Saturday)
    SOFT TISSUE SOFT TISSUE

    REQUESTED BY: ____________________________________________ REQUESTED BY: ____________________________________________


    “Above and beyond services” “Above and beyond services”
    Clinic Hours: 8:00 AM to 5:00 PM Clinic Hours: 8:00 AM to 5:00 PM
    (Monday to Saturday) (Monday to Saturday)

    You might also like