Patient Identifier (non PHI):
Gestational Age (if applicable):
Was fetus in the view (if applicable):
Study:
DLP:
Time of Tube Rotation:
mA:
mAs per Slice (if time & mA are not separate):
kVp:
CTDI-vol:
Length of scan (not scout):
Pitch:
Collimation setting of beam rows x width (not image reconstruction size)
Total Collimation: (images x number, not image thickness)
Equipment make/model:
Date of exposure:

Facility Name:
Facility Address:
Facility Phone:
Facility Fax:
Email:
Billing Address:
Contact: