                               SANTOSH DIAGNOSTIC

                                      & SCAN CENTRE

                           No. 69, ST. JOHN'S CHURCH ROAD, NEAR COLES PARK
                         BENGALURU - 560 005 · PHONES : 080-4925 4925, 4125 2600
                                     E-mail : sdsc@santoshhealthcare.com

                                     X - RAY REQUISITION


                                                                                     2/10/2023
                           Hajena,
    Name                                                                     Date.

                         87 Sex.               F
    Age.       .......                                      .I.P./ O.P. No

                              Dr Schi Rajendran.
   Referred by ..
                                                   Feeling lump
  Brief Clinical History ..

         both breasts                       - behind the nipples.

 .....
             Anxious about & lump in breast



                                                   USG both Breasts
 Examination Required ..




Pls give 6


                                                                                          Signature
dismomet .

{'clinic_pharmacy_details': {'clinic_pharmacy_name': 'SANTOSH DIAGNOSTIC & SCAN CENTRE', 'clinic_pharmacy_address': "No. 69, ST. JOHN'S CHURCH ROAD, NEAR COLES PARK", 'clinic_pharmacy_city': 'BENGALURU', 'clinic_pharmacy_pincode': '560 005'}, 'doctor_details': {'doctor_name': 'Dr. Schi Rajendran', 'doctor_qualifications': 'NA', 'doctor_registration_number': 'NA'}, 'patient_details': {'patient_name': 'Hajena', 'patient_age': '87', 'patient_gender': 'Female'}, 'prescription_details': {'date_of_doctor_consultation': '2/10/2023'}, 'procedure': {'chief_complaints_diagnosis': 'Feeling lump in both breasts - behind the nipples. Anxious about lump in breast'}, 'medicine_details': [{'medicine_name': 'dismomet', 'medicine_dosage': '1-0-1', 'medicine_frequency': 'Morning and Night', 'course_duration': '6'}], 'lab_test_details': {'lab_test_names': 'USG both Breasts', 'procedure_request': 'NA'}}