DIAGNOSTIC REPORT FORM

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Include the following items in a letter format:

Patient's Name and ID. Name of Referring Physician. Date of signature of Informed Consent.

Date of procedure and Institution performing the examinations.

Dear Dr (Name of Referring Physician):

The result of the (Procedure) performed on (Patient's Name ), is as follows:

Clinical History: Patient's  age and gender, diagnosis or referral information. Add any other relevant data.

Quality Control: Describe procedures in this regard (especially for Radiotracer and Equipment).

Comments: Any event which might affect the diagnostic examination being performed is listed here.

Description: Note in detail, abnormal features you see in the patient images in particular those related to the diagnosis under study.

Interpretation and Conclusions:

1) Interpretation refers to physiologic and pathologic syndrome or abnormality.
2) Conclusions, refers to most likely aetiology. Suggested follow-up of patient.

Dr (Name of Reporting Physician). Name of Physician validating the report.
e-mail and Cel Phone.

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