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086 295 7301 www.universal.co.za UNIVERSAL NETWORK RADIOLOGY REQUEST FORM MEMBER S DETAILS: Member s surname: Initials: ID no.: Health Plan : Membership no.: PATIENT S DETAILS: Patient surname: ID no.: Patient name: Age: Physical Address: Dependant code: Postal Address: Postal code: Postal code: REFERRING PRACTITIONER Doctor s name: Practice no.: ICD10 code: Date of appointment: CLINICAL INFORMATION RADIOLOGY SKULL 10100 30100 30110 30150 30155 Chest, single view Ches.

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