Erik Bradshaw DDS

 
 C-Sps & LSP 's 
 REPORT INFORMATION 
 CONTRAST: 
 GFR: 
 MRI History Form 
 INJECTION SITE: 
 FLOW RATE: 
 DOSE: TECH INITIALS: BL 
 CREATININE: 
 PT Fou OW UP APPT: 
 & 
 PATIENT'S NAME Erik Bradshaw DDS 
 ID# CIS583586 
 DATE: 12/2018/05
 PT WEIGHT 250 
 PATIENT PHONE: (558) 458-8585 
 AGE: 66 
 BIRTHDATE: 08/1998/21 
 REFERRER: Dr Cynthia Sullivan, MD 
 PHONE: (558)258-8586 
 FAX: (558)586-6589 
 Neck LBP. B arms & Legs. 
 IAGREE THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE. 
 PATIENT SIGNATURE: Jobbith 
 DATE: 02/2016/20
 REV:10/2016 
 RE2170581
