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TeleMed2U Imaging Order Form
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TeleMed2U Info
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ORDER DATE:
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ORDERING PHYSICIAN:
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ICD 10:
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COMMENTS:
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PHYSICIAN PREFERENCE FOR RESULTS
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US ORDER
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Text Field
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MYELOGRAM ORDER
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Text Field
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PET/CT ORDER
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Text Field
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MRI ORDER
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Text Field
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CT ORDER
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Text Field
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MRA/MRV ORDER
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Text Field
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X-RAY ORDER
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Text Field
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X-RAY ORDER- HEAD
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Text Field
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X-RAY ORDER- ABDOMEN
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Text Field
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X-RAY ORDER- SPINE
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Text Field
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X-RAY ORDER- CHEST
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Text Field
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ENT Orders Needed
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Text Field
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