IMAGING REQUEST

ELECTIVE STAT PORTABLE

Name: _ Sarmiento_____ __Benjie__________________________________

(Surname (Given Name) (Middle Name)
Address:
Date: 04/05/2021 Age: 10 Gender: Male
mnths. old
Out-Patient In-Patient Room: COVID Ward Birthday:
DIAGNOSTIC PROCEDURE
X-RAY ULTRASOUND Type of Examination:
CT SCAN 2D ECHO CXR-APL stat

Creatinine: Pedia
Adult
Height: _____
Weight: _____

CLINICAL DIAGNOSIS: Community Acquired Pneumonia - high risk with hypoxia.

Chua, Marielle P./Delos Reyes, E.

_______________________ NDU BSN 2 NDU CI
_______________________
Requesting Physician 04/05/2021 7:30AM Radiologic Technologist
Staff On Duty
Scheduled Case No: Note: All blanks must be properly filled up.
Time: Request must be sent prior to the examination.
 IMAGING REQUEST
ELECTIVE STAT PORTABLE

Name: _ Sarmiento_____ __Benjie__________________________________

(Surname (Given Name) (Middle Name)
Address:
Date: 04/05/2021 Age: 10 Gender: Male
mnths. old
Out-Patient In-Patient Room: COVID Ward Birthday:
DIAGNOSTIC PROCEDURE
X-RAY ULTRASOUND Type of Examination:
CT SCAN 2D ECHO CXR – decubitus

Creatinine: Pedia
Adult
Height: _____
Weight: _____

CLINICAL DIAGNOSIS: Community Acquired Pneumonia - high risk with hypoxia.

Chua, Marielle P./Delos Reyes, E.

_______________________ NDU BSN 2 NDU CI
_______________________
Requesting Physician 04/05/2021 7:30AM Radiologic Technologist
Staff On Duty
Scheduled Case No: Note: All blanks must be properly filled up.
Time: Request must be sent prior to the examination.