Health Care No ‫الرقم الصحي‬

Name ‫االسم‬
Age ‫العمر‬ Sex ‫الجنس‬
Nationality ‫الجنسية‬
Hospital : ALAMAL COMPLEX - Riyadh .Dept ‫القسم‬ Unit ‫الوحدة‬

X_RAY REQUEST & REPORT FORM ‫نموذج طلب تقرير االشعة‬

Source: <SOURCE>

Type Of Request:

Allergies :

L.M.P. .Contraceptive Pill: Pregnant:

Examination Requested: Appointment for x_ray

Brief Clinical Description : (Date and Time)

Diagnosis:

Patient’s Next Appointment with Clinic :

Physician’s Name: Signature: Date:

FOR USE OF X_RAY DEPARTMENT

Radiographer: Checked By:

Screening Time: X_Ray NO. :

POSITION KV MAS TOTAL NO. OF FILMS

35 x 43 35 x 35 30 x 40 35 x 40 24 x 30 18 x 24 DENTAL OCC

REPORT

Requested by : Signature: Date: