please print clearly Patient's Name _____________________________________ MRN _____________________
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DIGITAL REQUEST—please print clearly DATE__________________ Patient's Name _____________________________________ MRN _____________________ If you do not have patient’s name - provide demographics or R number __________________________________________________________________________________ __________________________________________________________________________________ Requestor____________________________ Telephone or Beeper number_________________ Originating Facility: ______________________________________________________________ Full description of exam: -Exam___________ Date_______ Contrast___ Non-Contrast_______ -Exam___________ Date_______ Contrast___ Non-Contrast________ -Exam___________ Date_______ Contrast___ Non-Contrast________ -Exam___________ Date_______ Contrast___ Non-Contrast________ -Exam___________ Date_______ Contrast___ Non-Contrast________ -Exam___________ Date_______ Contrast___ Non-Contrast________ Fax number: __________________ a copy of this sheet will be returned via fax Processed by: ____________________________ Import successful ___ failed____ Date________________ It is our intent to download all your outside images to synapse, however some discs are not compatible and cannot be imported. It is important to provide us with a name and number so we can contact you with any concerns. After processing, you can pick up your disc across from the coordinators office. Look for the requesting Dr.’s name on the envelope. We will make every attempt to import your disc within 24 hours. Please pick up processed disc in a timely manner so you will have them for your records.
