          X - Ray No. :
                              Department
                                    ThereUse.
                                       forisFemales
                                             noRef. only
                                               possibility
                                                    By     of me
                                                       Doctor  : being pregnant.
                                                                Select
                                                                   Please
                                                                       :
                                                                                                       IP No.       Patient Name
                                                                                                                              Request For X - Ray / of
                                                                                                                                       Department   Ultra Sound /and
                                                                                                                                                       Radiology  Dopp
                                                                                                                                                                     Im




                                                                 Infection Risks



                                                                                             Examination Requested :
                                          Consultant Obstetrics Na 17
                                                                                   Early may sean                      Shrutika Charhan.
                                       Motherhood Seriepur
                                                    Dr. Archana Pathak

                                                 KMC Reg No. 97987

                                             MUSS, DNS



                                                                 Diabetic                              Ward


                4
         Date




                                              Signature

                                                                                                       Portable [
                                                                Known Allergies
                                                                                                                    Age / Sex



         Signature of Radiographer :
                                                                                             Clinical Indication
                                                                                                        EmergencyFor The Request :


                                                                                   2/5/23.


                                                                                                                                womenmotherhe
                                                                                                                                      & children's hospital
                                                                                                                    Hosp.No.

                                                                Impaired renal function               M.L.C. :- YES
                                             Date:




                                                                                                      NO

                                                                                                                            2



F- 032

{'clinic_pharmacy_details': {'clinic_pharmacy_name': "women & children's hospital", 'clinic_pharmacy_address': 'NA', 'clinic_pharmacy_city': 'NA', 'clinic_pharmacy_pincode': 'NA'}, 'doctor_details': {'doctor_name': 'Dr. Archana Pathak', 'doctor_qualifications': 'NA', 'doctor_registration_number': 'NA'}, 'patient_details': {'patient_name': 'Shrutika Charhan.'}, 'prescription_details': {'date_of_doctor_consultation': '2/5/23.'}, 'procedure': {'chief_complaints_diagnosis': 'Early may sean'}, 'medicine_details': [], 'lab_test_details': {'lab_test_names': 'NA', 'procedure_request': 'Request For X - Ray / Ultra Sound / Doppler / Echo Examination'}}