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Prime Medical

PRIME Medical Request Form

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PATIENT’S INFORMATION

Name:
Sex:

DOCTOR’S INFORMATION

EXAMINATION REQUESTED(Please tick / indicate below)

CT Scan
CT Angiogram
Ultrasound
Fluoroscopy
PROCEDURES
X-Ray
MRA MRV
MRI
Report
Images

DOCTORS BOOK AND USE OUR FACILITIES

BLOOD TESTS

Hematology Panel:
Comprehensive Metabolic Panel
OTHER TESTS
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