4-6.
REQUESTOR'S NAME, SIGNATURE, TELEPHONE/PAGER NUMBER AND
DATE BLOCKS
Refer to figure 4-11. The requesting physician's name should be printed or typed
in the requestor's name block. The physician's signature should appear in the signature
block. The requester's telephone number and page number should be indicated in the
appropriate block. The date of the request should also be indicated. It should be noted
that many X-ray request slips are sent back because the referring physician failed to
provide his or her signature on the form.
Figure 4-11. Requestor information blocks.
MD0961
4-13
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