CT Scan Requisition Form

WEE Diagnostics

CT Scan – Requisition Form

District Hospital: ____________________

ROUTINE / URGENT Routine Urgent Date
Patient name
Gender M F Others Age yrs months
Address
Phone no
(Only For Females) Pregnancy Yes No LMP
Patient History
Chief complaints
Provisional diagnosis
Type of Patient OPD IPD No
Type of Patient AYUSHMAN BPL APL DEEMED Free OTHERS
AYUSHMAN Number BPL Number
Is it a Repeat Scan Yes No Reason (If Yes)
SCAN TYPE – PLAIN / CONTRAST PLAIN CONTRAST If contrast study then NBM for 4 to 6 hrs Yes No
Serum Creatinine Blood Urea
Brain Pelvis
PNS/ORBIT/PITUITARY Spine
HRCT TEMPORAL ANGIOGRAPHY (RENAL / BRAIN / CORONARY)
FACE JOINTS
NECK EXTREMITIES
HRCT THORAX OTHERS
WHOLE ABDOMEN TOTAL NO. OF SCANS PRESCRIBED

Sign & Seal of CS / CMHO (Only for Scan declared free)
Reason for Free Scan:

Sign & Seal of Prescribing Doctor
Doctor’s Full Name:

WEE DIAGNOSTICS, MBS HOSPITAL,KOTA (RAJ)