Easy Imaging Ltd Plymouth Consultant Radiologists Referral Form
PATIENT DETAILS
Surname: ……………………………First Name: ………………………… Date of Birth:……………………………. Home Address: ……………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………. Tel No (Daytime): …………………………………… Tel No (Evening): ………………………………………………. PAYMENT DETAILS - (Please circle and give invoice details below if necessary) Self Funding
Invoice to be addressed to: …………………………………………………………………………………………….…. ……………………………………………………………………………………………………………….………………. CLINICAL DETAILS
Suggested Examination: ………………………………………………………………….……………………………… Clinical Indications: ……………………………………………………………………………….……………………… …………………………………………………………………………………………………….…………………………. …………………………………………………………………………………………………….…………………………. Provisional Diagnosis: ………………………………………………………………….………………………………… Please identify if the patient has any of the following:
Pacemaker: Yes / No
Electronically/magnetically operated implant devices: Yes / No
On Warfarin
History of Intraoccular metallic Foreign Bodies: Yes / No
Please specify:….…………………………………………………………………….
Please specify:…………………………………………………………….………….
Referrer’s Signature: …………………………………………… Date: ………………………………………………… Name (please print): ………………………………………………………………………………………….…………… Address to which results are to be sent: ………………………………………………………………………………… ………………………………………………………………………………………………………………………………. A CD copy of the images for the patient and referrer is included in the cost of the examination Additional Copy CD (extra charge) of images requested: Yes / No Completed forms to be sent to Easy Imaging, Plymouth Consultant Radiologists, PO Box 231, Plymouth, PL6 8WY, faxed to 01752 763257 or emailed to enquires@easyimaging.co.uk (Tel: 01752 432200)
Gender Differences in College Students’ Future Aspirations Materials and Measures M = 1.70 , SD = 1.33, Females M = 1.42, SD = 1.18), but for other events (e.g., having a career), they felt a lot of pressure (Males M = 2.63 , SD = Gender studies show that men and women prioritize different life goals. The demographic portion of the questionnaire consisted of four questions
• Wholesale and retail establishment are more – Large number of small stores– Twice the per capita number of stores as US• Number of establishments / 1000 people• Smaller establishments – workers per – Extensive use of resale price maintenance – Lax anti-trust enforcement allows retail cartels– Most important policy was the Large Scale Retail Law • Covered stores that had
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