                                                                                                                                 RDL-F-01
                        DEPARTMENT OF RADIODIAGNOSIS REQUISITION / REFERRAL FORM


Name of Patient :                    Mrs.           Annu Sethia                                                       42
                                                                                                        Age :
Father's / Husband's Name :                                                                           up to: 11637904J

Referred by               DI. T.K Saha                                                    1/8/23 Ward Name: Dichnis
                                                                                Date :

   History (Relevant Positive & Negative points including allergies)




   Date of LMP -
   Past h/o Imaging procedures (Reaction to contrast if any)




                                                            C.R.F
    Diagnosis (Clinical & Anatomical) :




                                                                        Suturing chages


   Investigation (s) required (with anatomical region).




                                                                                                     Signature of Referring Doctgr




Instructions overleaf
                                                                       "CONFIDENTIAL"

{'clinic_pharmacy_details': {'clinic_pharmacy_name': 'NA', 'clinic_pharmacy_address': 'NA', 'clinic_pharmacy_city': 'NA', 'clinic_pharmacy_pincode': 'NA'}, 'doctor_details': {'doctor_name': 'DI. T.K Saha', 'doctor_qualifications': 'NA', 'doctor_registration_number': 'NA'}, 'patient_details': {'patient_name': 'Mrs. Annu Sethia'}, 'prescription_details': {'date_of_doctor_consultation': '1/8/23'}, 'procedure': {'chief_complaints_diagnosis': 'C.R.F'}, 'medicine_details': [], 'lab_test_details': {'lab_test_names': 'NA', 'procedure_request': 'NA'}}