Johnathan Shea

 
 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 Johnathan Shea 
 ID# CIS693696 
 DATE: 20-08-18
 PT WEIGHT 250 
 PATIENT PHONE: (569) 469-8695 
 AGE: 84 
 BIRTH DATE: 90-10-25 
 REFERRER: Dr Wesley Arnold, MD 
 PHONE: (569)269-8696 
 FAX: (569)696-6699 
 Neck LBP. B arms & Legs. 
 IAGREE THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE. 
 PATIENT SIGNATURE: Jobbith 
 DATE: 18-02-11
 REV:10/2016 
 RE2170691
