Transcription of Electrocardiogram Requisition REQ9015ECG
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Electrocardiogram Requisition REQ9015ECG
APPOINTMENTS - WEBSITE BOOKING: OR CALL 403-770-5136. GENERAL INQUIRIES 403-770-3600 Electrocardiogram Requisition PHNA ddressDate of Birth PhonePhoneCopy to(last, first)PhoneCopy to(last, first)PhoneAlternate Identifier(yyyy-Mon-dd)Last NameFirst NameMiddleGender M FCity/TownProvPostal CodeLocationRequestor Name(last, first)Location/Facility/AddressLocation/ Facility/AddressLocation/Facility/Addres sHealthcare Provider IDHealthcare Provider IDHealthcare Provider IDPatientRequestor (s)CollectionDate (yyyy-Mon-dd)Time (24 hr)LocationCollector ID Laboratory Information Centre: 403-770-3600 Page 1 REQ9015 ECG 20160812 Accession # (lab only) Interpretation Request Stat ECGs are not available. Patients with cardiac symptoms should be referred to nearest emergency department. All ECGs on patients 16 years or younger are read by a pediatric cardiologist Select preferred reader and interpretation status.
ELECTROCARDIOGRAM REQUISITION PHN Address Date of Birth Phone Phone Copy to (last, first) Phone Copy to (last, first) Phone Alternate Identifier (yyyy-Mon-dd) Last Name First Name Middle Gender M F City/Town Prov Postal Code Location Requestor Name (last, first)
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