VISION DIAGNOSTIC SDN BHD diagnostic · 2013. 1. 31. · diagnostic VISION DIAGNOSTIC SDN BHD (...
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/ / diagnosc VISION DIAGNOSTIC SDN BHD ( 637499-M) 127, Jalan SS 6/12, 47301, Kelana Jaya, Petaling Jaya, Selangor D. E., Malaysia. Tel : 603-7803 8300 Fax : 603-7803 8302 Email : [email protected] Website: www.vision.edu.my Opening Hours: Mon – Fri (9.00am – 5.00pm) Paent Name IC/Passport No. DOB (dd/mm/yyyy) Sex Reg. No. Paent’s Address Referring Doctor’s Name, Address & Doctor’s Code (Please include clinic chop) Chest Cervical Spine Thoracic Spine Lumbosacral Spine Abdomen KUB Skull Facial Bones Nasal bones Mandible Mastoids Temporo-Mandibular Joint Paranasal Sinuses Shoulder Humerus/Arm Elbow Joint Forearm Wrist Joint Hand (Single / Both) Thumb Or Single Digit Clavical Sterno-Clavicular Joint Leſt Hand For Bone Age Acromio-Clavicular Joints Sternum Scapula Scaphoid Pelvis Hip Joint Femur Knee Leg Ankle Foot Heel/Calcaneum FOMEMA Up To Four View And One Addional View And Two Addional View And Limited Ultrasound Addional Doppler Ultrasound For Other Organs (Per Organ) Ultrasound Musculoskeletal, To Specify :________________ Ultrasound Scrotum Detailed Scan Of Fetus (2nd Trimester) Doppler Ultrasound Of Extra- Cranial Carods Doppler Ultrasound Of Renal Arteries Doppler Ultrasound Of Deep Veins (Single / Two Limbs) 1st Trimester Obstetrics Scan 3rd Trimester Obstetrics Scan Breast Transvaginal Ultrasound Thyroid Upper Abdomen KUB Female Pelvis X-rays: Mammograms: Ultrasound Scans: Phone No. CLINICAL HISTORY / INDICATION ADDITIONAL TESTS Date ______/______/______ (dd/mm/yyyy) Doctor’s Signature _________________ LMP: ______dd/______mm/______yy Bill to : Cash / Panel / Medical Card : ____________________________________________ PATIENT REFERRAL FORM 9001:2008 Certificate No: 6642 Radiographer / Sonographer LPPKN PERKESO HEALTH SCREENING PACKAGES Others: GA_CI_PR_20130114/01
Transcript of VISION DIAGNOSTIC SDN BHD diagnostic · 2013. 1. 31. · diagnostic VISION DIAGNOSTIC SDN BHD (...
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diagnosticVISION DIAGNOSTIC SDN BHD ( 637499-M)
127, Jalan SS 6/12, 47301, Kelana Jaya,Petaling Jaya, Selangor D. E., Malaysia.Tel : 603-7803 8300 Fax : 603-7803 8302Email : [email protected]: www.vision.edu.my
Opening Hours:Mon – Fri (9.00am – 5.00pm)
Patient Name
IC/Passport No.
DOB (dd/mm/yyyy) Sex Reg. No.
Patient’s Address
Referring Doctor’s Name, Address & Doctor’s Code(Please include clinic chop)
Chest Cervical Spine Thoracic Spine Lumbosacral Spine Abdomen KUBSkull Facial Bones Nasal bones Mandible Mastoids Temporo-Mandibular Joint
Paranasal Sinuses Shoulder Humerus/Arm Elbow Joint Forearm Wrist Joint Hand (Single / Both)Thumb Or Single Digit Clavical Sterno-Clavicular JointLeft Hand For Bone Age Acromio-Clavicular Joints
Sternum Scapula Scaphoid Pelvis Hip JointFemur Knee Leg Ankle FootHeel/Calcaneum FOMEMA
Up To Four View And One Additional View And Two Additional View And Limited Ultrasound Additional
Doppler Ultrasound For Other Organs (Per Organ) Ultrasound Musculoskeletal, To Specify :________________Ultrasound Scrotum
Detailed Scan Of Fetus (2nd Trimester) Doppler Ultrasound Of Extra- Cranial Carotids Doppler Ultrasound Of Renal Arteries Doppler Ultrasound Of Deep Veins (Single / Two Limbs)1st Trimester Obstetrics Scan3rd Trimester Obstetrics Scan
Breast Transvaginal UltrasoundThyroid Upper Abdomen KUBFemale Pelvis
X-rays: Mammograms:
Ultrasound Scans:
Phone No.
CLINICAL HISTORY / INDICATION
ADDITIONAL TESTS
Date ______/______/______ (dd/mm/yyyy) Doctor’s Signature _________________
LMP: ______dd/______mm/______yy
Bill to : Cash / Panel / Medical Card : ____________________________________________
PATIENT REFERRAL FORM9001:2008
Certificate No: 6642
Radiographer / Sonographer
LPPKNPERKESOHEALTH SCREENING PACKAGES
Others:
GA_CI_PR_20130114/01
One Utama : 7.2km
Ikea (Ikano Power Cente) : 8.5km
Sunway Pyramid : 8.9km
KLCC : 21.6km
Midvalley Megamall : 12.7km
Distance :
MBPJ Sports Centre : 3.1km BANDAR SUNWAY
SS3
TO KL >
KELANA JAYA
SS2DAMANSARA JAYA
DAMANSARA UTAMA
ATRIAKelana Jaya LRT
Kelana JayaMedical Center
ShellRecreation Park
MBPJSportCenter
MASTrainingCenter
KelanaSeafoodCentre
SubangGolfcourse
LeisureCommerceSquare
NanyangMotorola
Giant Hypermarket
Shell
Pos Office
School
TropicanaGolfcourse
HyattSaujanaGolfcourse
Subang Airport
EON HQGlenmarieGolfcourse
SubangParade
Wisma Mesiniaga
DAMANSARA JAYA
NE
W K
LA
NG
V
AL
LE
Y
< TO PORT KLANG
< TO SHAH ALAM
TO KL >
LDP
FEDERAL HIGHWAYS
LDP
BANDAR UTAMA
LDP
Yamaha
127 Jalan SS6/12,Kelana Jaya,47301 Petaling Jaya,Selangor.
We are here:
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Diagnostic Centre
Diagnostic Centre
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