Swedish Imaging Records Center Image Request Form
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Your Information Details
1.
Today's date
*
2.
Your facility name
*
3.
Date needed by
*
4.
Contact last name
*
5.
Contact first name
*
6.
Contact phone number
*
Example: 555-555-5555
7.
I want to
*
-- Please Select --
Request images from an outside facility
Request images from the Swedish Central File Room
Send images to the Swedish Central File Room
Send images from an internal department (SMC/SMG)
8.
I want to send/receive images in the following format
*
-- Please Select --
CD/DVD
Electronic
Other
Patient Information
9.
Patient last name
*
10.
Patient first name
*
11.
Patient middle initial
*
12.
Patient date of birth
*
13.
Swedish MRN (if applicable)
Study Details
14.
Provide the following information about each study. If you'd like to enter more than one, click on the green plus icon on the right.
Exam description
Exam date
Modality
1
01/01/1900-12/31/2100
-- Please Select --
MR
CT
US
XR
Mammo
Other
2
01/01/1900-12/31/2100
-- Please Select --
MR
CT
US
XR
Mammo
Other
3
01/01/1900-12/31/2100
-- Please Select --
MR
CT
US
XR
Mammo
Other
4
01/01/1900-12/31/2100
-- Please Select --
MR
CT
US
XR
Mammo
Other
5
01/01/1900-12/31/2100
-- Please Select --
MR
CT
US
XR
Mammo
Other
6
01/01/1900-12/31/2100
-- Please Select --
MR
CT
US
XR
Mammo
Other
7
01/01/1900-12/31/2100
-- Please Select --
MR
CT
US
XR
Mammo
Other
8
01/01/1900-12/31/2100
-- Please Select --
MR
CT
US
XR
Mammo
Other
9
01/01/1900-12/31/2100
-- Please Select --
MR
CT
US
XR
Mammo
Other
15.
Special instructions
Done