Miller Radiology
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Clinic Log Sheet
Client Contact Information
Clinic Name
Office Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone #
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Fax #
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Business Contact
First Name
Last Name
Business Contact Title
Business Contact Phone #
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Business Contact Email
Technologist Contact
First Name
Last Name
Technologist Contact Phone #
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Technologist Contact Email
Days/Hours of Operation
Fax for Report Delivery
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Email for Report Delivery
Phone # For Urgent Findings
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Providers On Staff
IT Contact
First Name
Last Name
IT Contact Phone #
(###)
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