Delivery Order Form

Delivery Order Form - Lithgow

ALFRED IMAGING GROUP

LITHGOW HOSPITAL RADIOLOGY DEPARTMENT - DELIVERY ORDER FORM

Delivery Address:

LITHGOW HOSPITAL RADIOLOGY DEPARTMENT

Col Drewe Drive

Lithgow - 2790

Large X-ray Envelope 5,000 10,000 others

If others, Please Specify

Medium X-ray Envelope 5,000 10,000 Others

If others, Please Specify

A4 Letterhead 10,000 20,000 Others

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A4 Referral Sheets (100 in a pack) 100 Pads 200 Pads Others

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A5 Referral General Pad (50 in a pad) 100 Pads 200 Pads 300 Pads Others

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A5 Referral Dr's Personalised Pad (50 in a pad) 2 Pads 4 pads 6 pads Others

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Referring Doctor

Please enter the referring Doctor's information below.

Doctor's Name

Address

Phone

Fax

Provider No

Patient Labels 5,000 10,000 Others

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Appointment Cards 5,000 10,000 Others

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DL Envelopes 5,000 10,000 Others

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DL with Window Envelopes 5,000 10,000

If others, Please Specify

Delivery Date

Notes

Ordered By

Approved By

Attachment