Citywide Order Form
Ugorji Radiology Consultants, LLC
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
/
Month
/
Day
Year
Date
Patient Birth Gender
*
Male
Female
Body Part
Brain (Duramap™ ONLY)
Brain (Structural ONLY)
Brain (Duramap™ AND Structural)
Cervical Spine (Duramap™ ONLY)
Date of Injury
*
/
Month
/
Day
Year
Date
Rx form
*
Browse for Rx PDF
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of
Clinical Notes, Diagnosis and additional comments
*
DICOM image upload - Zip file only
*
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of
Normative Data
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URC
Ordering Company
17595 Harvard Avenue
Suite C - 10259
Irvine, CA 92614
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