Patient Identifier (non-PHI):
Gestational Age (if applicable):
Study Type:
Number of exposures:
Technique:
kVp:
Date of exposure:
mAs per Slice (if time & mA are not separate):
Equipment make/model:

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