Image Transfer Notification Web Form

Image Location/Sending Facility

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Patient Information

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Last, First Middle

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mm/dd/yyyy

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Order Information

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Last, First Middle

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mm/dd/yyyy

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Official Interpretation

Reference Only - no interpretation

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Please provide description of additional procedure(s) to include procedure name(s) and number of images.

Historical Exam Information

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Please provide Description of Historical Exam(s) to include Procedure name(s), number of images, date(s) of exam(s)

Results Information





Children's Hospital and Clinics of Minnesota - Radiology
St. Paul Department Phone#: 651-220-6147 and Fax #: 651-220-5436
Minneapolis Department Phone#: 612-813-8200 and Fax #: 612-813-6397