New Radiology Order

Patient*

Source

Priority

Ordering Doctor*

Examination*

Laterality

Contrast Required

Yes

Clinical Indication*

Relevant Clinical History

Provisional Diagnosis

Special Instructions

Safety Screening

Pregnancy status confirmed / not applicable

No contraindicated implant/device (if MRI)

Contrast allergy history reviewed (if contrast)

Patient/representative consent obtained for contrast/interventional procedure (where required)

Charges for the selected examination will be added to the patient's bill on order confirmation.

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