Radiology Consultation

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Radiology Consultation
Doctor’s Name & Address
Work Phone
Other Phone
Reference #
Patient
Date
File
Age
First visit on
Sex
D O B
Date of X-Rays
X-Rays to view
14 x 17
7 x 17
8 x 10
Major complaint
Diagnosis
Area in question
Referring Doctor’s Comments
Radiologist’s Comments

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Parent category: Medical
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