No Yes

RadLink Diagnostic Imaging (S) Pte Ltdwww.radlink.com.sg

Dr. Anne Tan Kendrick MA, BMBCH, FRCR, FAMS

Dr. Eng Chee Way MBBS, M Med, FRCR

Dr. Gi Ming Tye MBBS, M Med, FRCR

Dr. June Chong L MMBBS, FAMS, ABR, CAQ

Dr. Lee Chin Hwee MBBS, FRCR, M Med

Dr. Niketa Chotai MBBS, MD, FRCR, FUOT (Canada)

Appointment Date:

Surname

Given Name

NRIC/Passport No:

Date of Birth:

Nationality:

Age/Gender:

Local Address:

Contact Number:

Time (AM/PM):

Films Required?Yes No

Self-collection

Dispatch to clinic

By Patient

By Clinic

Bill Guarantor:

Payment Mode

Patient’s Next Appointment With Doctor

Date

Name & Signature of Requesting Doctor/ Clinic’s Address

Delivery Mode

(______________)

DVD Required? Doctors’ Portal Delivery?

RadLink Diagnostic Imaging (S) Pte Ltd290 Orchard Road #08-04, #08-07 to 12 Paragon Medical (Tower 1 Lift, Lobby E or F)S’pore 238859 Tel: (65) 6836 0808 Fax: (65) 6836 8484 Drs Lim, Hoe and Wong Radiology Pte Ltd1 Grange Road #06-03 Orchard Building S’pore 239693Tel: (65) 6737 3311 Fax: (65) 6738 1159 Blk 186 Toa Payoh Central #01-430 S’pore 310186Tel: (65) 6255 0201 Fax: (65) 6255 6435 Jurong Point Medical Centre #B1A-19C Jurong Point Shopping Centre1 Jurong West Central 2 S’pore 648886 Tel: (65) 6792 6119 Fax: (65) 6792 1170 Medical Imaging Pte LtdCairnhill X-Ray & Diagnostic Centre290 Orchard Road #15-04 Paragon Medical (Tower 1 Lobby F)S’pore 238859 Tel: (65) 6238 3610 Fax: (65) 6738 5133 Ang Mo Kio X-Ray Clinic & LaboratoryBlk 422 Ang Mo Kio Ave 3 #01-2516 S’pore 560422Tel: (65) 6459 9806 Fax: (65) 6455 9462 Tampines Street 11 X-Ray ClinicBlk 138 Tampines Street 11 #01-130 S’pore 521138Tel: (65) 6785 7409 Fax: (65) 6781 2703

Contact Number: Date:

Radiological Examination

Clinical Diagnosis / Current Problem

Asthma:Diabetes:Drug Allergy:

Remarks:

Old Films / Reports

If yes, state quantity:

___________(DVD) ___________(Films) ___________(Report)

Radiographer’s Remarks:

(For internal use only)

Time:

Yes No Yes No

Yes NoNo YesNo Yes

For Radlink Diagnostic Imaging (s) Pte Ltd only:

FD:

(DDMMYYYY)

[Please paste sticker label here]

V8.5

I have been advised that this radiological procedure may have an adverse effect on a foetus and I hereby warrant that I am not pregnant.

Name:_____________________________________________________________

LMP:_______________________________________________________________

NRIC / PP:__________________________________________________

Signature / Date:______________________________________________