Sample, Sammy G ST0001

Followup Form 1234567890


MM/DD/YYYY
MM/DD/YYYY

Ordering Information

Ordering information is required ONLY for Medicare/Medicaid patients.
First Name
Last Name

(shared decision making is required for reimbursement for G0297 exams on baseline only )


information will be copied to CT report




MM/DD/YYYY
MM/DD/YYYY

Smoking

Day
Month
Year