Name of facility and city:

Resident's Name:

Resident's D.O.B.:

Resident's Room Number:

Required Exam:

Diagnosis or symptoms ("Rule out" is not acceptable):

Does the patient have any communicable diseases or skin infections? Yes No

Please specify:

Ordering Physician:

Is there any time in the next 48 hours that the patient will be unavailable for the test? Yes No

Please specify when:

Please fax the resident's face sheet and the physician's order for the test to 989-892-7455