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AMIC Radiology STAT Call Form Version 2
Published: 4/7/2015
All Items Must be Completed

Site  
Patient Name (Last, First) ,
Source
Modality
Exam Description  
History  
Call Report To Name:  
Call Report to Phone#:  

 These fields will only be enabled if the requesting site has patient waiting enabled.
Is the patient waiting
Patient Location  
Please do not enter the patient's personal phone number in this field. 
Patient Location Phone  


For use only during a EPIC downtime.
****** Please indicate if this a STAT exam ******
 Contrast Amount in ML:   Contrast Type:

  Please be patient after hitting Submit
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