Interventional Imaging Request Form

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First Name *

Date *

Medical Aid Society *

Medical Aid Number *

Date of Birth *

Gender *MaleFemale

L.M.P *

Message0 / 180

BiopsyAscitic Drain InsertionChest Drain Insertion

AngioplastyPicc LineVenous PortDialysis Access

NephorostomyStentOther

Trans Hepatic CholangiographyBiliary DrainageBiliary StentOesophageal Stent

IVC Filter InsertionThrombolysisTumour EmbolizationFibroid EmbolizationFallopian Tube RecanalizationMicrowave Ablation

Clinical History *

Examination Requested *

Referring Doctor *

MIC Radiology Group is a Medical Practice which provides specialized Diagnostic, Interventional and Women’s Imaging Services.

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