Image Transfer Notification Web Form


Date: NOTE: * indicates a required field.

Image Location/Sending Facility:

*
     

Patient Information:

Patient Name: * Patient Address:
Date of Birth: * (mm/dd/yyyy) *
Sending Facility
MRN/Pt ID:
* * *
Phone #: Gender:
Parent or
Guardian Name:
* *
Relationship: *

Order Information:

Ordering Provider: *
Request for:  * (select 1)
Official Interpretation
STAT & Call
ASAP in AM
Within normal workflow
Reference Only - no interpretation
Images Only
Diagnosis/Symptoms: *
Exam Date: * (mm/dd/yyyy)
Number of Images: *
Procedure Category: *
Procedure: *
Additional Procedures:

Historical Exam Information:

Historical Exams Included?   Yes    No *

Results Information:

Ordering Provider
Preliminary Interpretation: Normal   Abnormal
Comments:
Radiologist Interpretation Determination:
    Agree  Disagree
M.D. Notification?: Yes  No
Patient Notification?: Yes   No
Children's Hospital and Clinics of Minnesota - Radiology
St. Paul Department Phone#: 651-220-6147 and Fax #: 651-220-5436
Minneapolis Department Phone#: 612-813-8200 and Fax #: 612-813-5857