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["【ＣＴ／ＭＲＩ検査】　検査依頼書/診療情報提供書"]
["検査申込日",null,null,null,null,"年",null,"月",null,"日"]
["患者さんがWEB予約を希望する場合は下記へ☑を入れて下さい"]
["WEB予約希望",null,null,null,null,null,null,null,null,null," 医療機関名"]
["検査希望日　※WEB予約を希望された場合は記載不要",null,null,null,null,null,null,null,null,null," 所在地"]
["第一希望",null,null,"月",null,"日","(　　)",null,"時","台"," TEL/FAX",null,null,null,null,null,"／"]
["第二希望",null,null,"月",null,"日","(　　)",null,"時","台"," 医師名"]
["患者基本情報"]
["フリガナ",null,null,null,null,null,null,null,null,null,null,"生年\n月日",null,null,"大正",null,"昭和",null,"平成",null,"令和"]
["患者\n氏名",null,null,null,null,null,null,null,"旧姓",null,null,null,null,null,"年",null,"月",null,"日",null,"才"]
["住所",null,null,null,null,null,null,null,null,null,null,"性別",null,"男性","TEL"]
["身長",null,null,null,null,"㎝","体重",null,null,null,"㎏",null,null,"女性"]
["※頭部CT・MRI撮影枠"]
["月曜日　　　８：４５～１５：１５　　火～金曜日　８：４５～１１：１５\n\n※貴院の休診日はなるべく避けてください。上記以外希望の場合はご相談ください。",null,null,null,null,null,null,null,null,null,null,null,"画像郵送\n方法",null,null,"後日郵送　（1週間以内）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"当日患者渡し *読影レポートは後日郵送"]
["検査項目\n【CT】",null,"頭部",null,"頭部",null,null,null,"眼窩",null,"脊椎",null,"頸椎"]
[null,null,null,null,"副鼻腔",null,null,null,"頚部",null,null,null,"胸椎"]
[null,null,null,null,null,null,null,null,null,null,null,null,"腰椎"]
[null,null,"胸部／腹部\n／骨盤腔",null,"胸部（肺野・縦隔）",null,null,null,null,null,"関節／他",null,"股関節"]
[null,null,null,null,"腹部（肝臓上緑から腎下極まで）",null,null,null,null,null,null,null,"上肢（部位：",null,null,null,null,null,null,null,"）"]
[null,null,null,null,"骨盤腔",null,null,null,null,null,null,null,"（撮影範囲：",null,null,null,null,null,null,null,"）"]
[null,null,null,null,"腹部から骨盤腔",null,null,null,null,null,null,null,"下肢（部位：",null,null,null,null,null,null,null,"）"]
[null,null,null,null,"胸部から上腹部",null,null,null,null,null,null,null,"（撮影範囲：",null,null,null,null,null,null,null,"）"]
[null,null,null,null,"胸部から骨盤腔"]
["検査項目\n【MRI】",null,"頭部",null,"頭部(MRI/MRA)・頚部MRA",null,null,null,null,null,"腹部／\n骨盤部",null,"肝臓",null,"胆・膵（MRCP）",null,null,null,"腎臓"]
[null,null,null,null,"頭部・内耳道MRI",null,null,null,"下垂体",null,null,null,"膀胱",null,"前立腺",null,null,"婦人科（子宮・卵巣）"]
[null,null,null,null,"物忘れ（VSRAD）",null,null,null,"眼窩",null,"脊椎",null,"頸椎",null,null,"胸椎",null,null,"腰椎"]
[null,null,null,null,"副鼻腔",null,null,null,"頚部",null,null,null,"胸腰椎移行部（第8胸椎～第5腰椎まで）"]
[null,null,"関節／他","　肩関節（",null,null,"みぎ",null,"ひだり　　）",null,null,null,"　股関節（",null,null,"みぎ",null,"ひだり　　）"]
[null,null,null,"　肘関節（",null,null,"みぎ",null,"ひだり　　）",null,null,null,"　膝関節（",null,null,"みぎ",null,"ひだり　　）"]
[null,null,null,"　手関節（",null,null,"みぎ",null,"ひだり　　）",null,null,null,"　足関節（",null,null,"みぎ",null,"ひだり　　）"]
[null,null,null,"　手　　　（",null,null,"みぎ",null,"ひだり　　）",null,null,null,"　足　　　（",null,null,"みぎ",null,"ひだり　　）"]
[null,null,null,null,"上肢その他（",null,null,null,null,null,null,"）",null,"下肢その他（",null,null,null,null,null,null,"）"]
["【検査目的】"]
[]
["【臨床診断】"]
[]
["【撮影指示 等】"]
[]
[]
[]
[]
[]
["地域医療連携室　連絡先\n《　ＦＡＸ　０４３－４８６－１８０７　》\n《　ＴＥＬ　０４３－４８６－５５１１　》\nお問い合わせ　月-金　8:30-17:00　／　土　8:30-12:00　（年末年始・祝日除く）　　　2026/4月改定"]

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["【ＣＴ検査】　検査依頼書/診療情報提供書"]
["検査申込日",null,null,null,null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null," 医療機関名"]
["検査希望日",null,null,null,null,null,null,null,null,null," 所在地"]
["第一希望",null,null,"月",null,"日","(　　)",null,"時","台"," TEL/FAX",null,null,null,null,null,"／"]
["第二希望",null,null,"月",null,"日","(　　)",null,"時","台"," 医師名"]
["患者基本情報"]
["フリガナ",null,null,null,null,null,null,"性別",null,"男","保険情報",null,null,null,"健康保険証",null,"／","交通事故",null,null,"労災"]
["患者\n氏名",null,null,null,null,null,null,null,null,"女","保険証番号"]
["生年\n月日",null,null,"大正",null,"昭和",null,"平成",null,"令和","被保険者証\n記号・番号"]
[null,null,null,"年",null,"月",null,"日",null,"才","被保険者との続柄",null,null,null,null,"本人",null,"家族","／","事故・労災"]
["住所",null,null,null,null,null,null,null,null,null,"公費負担番号"]
["ＴＥＬ",null,null,null,null,null,null,null,null,null,"公費負担医療の\n受給者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"負担割合",null,null,"割","負担"]
["検査依頼／診療情報"]
["造影検査\nの有無",null,null,"単純のみ",null,null,null,null,null,null,null,null,"画像郵送方法",null,null,"後日郵送（1週間以内）"]
[null,null,null,"造影検査",null,"Cr：",null,null,"eGFR：",null,null,null,null,null,null,"当日患者渡し * 読影レポートは後日郵送"]
["検査項目",null,"頭　部",null,"頭部",null,null,null,"眼窩",null,"脊 椎",null,"頸椎"]
[null,null,null,null,"副鼻腔",null,null,null,"頚部",null,null,null,"腰椎"]
[null,null,null,null,"その他（",null,null,null,null,"）",null,null,"胸椎"]
[null,null,"胸部／腹部／骨盤腔",null,"胸部（肺野・縦隔）",null,null,null,null,null,"関　節　／　他",null,"股関節"]
[null,null,null,null,"腹部（肝臓上緑から腎下極まで）",null,null,null,null,null,null,null,"上肢（部位：",null,null,null,null,null,null,null,"）"]
[null,null,null,null,"骨盤腔（第3腰椎下緑から坐骨まで）",null,null,null,null,null,null,null,"（撮影範囲：",null,null,null,null,null,null,null,"）"]
[null,null,null,null,"腹部から骨盤腔",null,null,null,null,null,null,null,"上肢（部位：",null,null,null,null,null,null,null,"）"]
[null,null,null,null,"胸部から骨盤腔",null,null,null,null,null,null,null,"（撮影範囲：",null,null,null,null,null,null,null,"）"]
["【検査目的】"]
[]
["【臨床診断】"]
[]
["【撮影指示 等】"]
[]
[]
[]
["地域医療連携室　連絡先\n《　ＦＡＸ　０４３－４８６－１８０７　》\n《　ＴＥＬ　０４３－４８６－５５１１　》\nお問い合わせ　月-金　8:30-17:00　／　土　8:30-12:00　（年末年始・祝日除く）"]

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["【ＭＲＩ検査】　検査依頼書/診療情報提供書"]
["検査申込日",null,null,null,null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null," 医療機関名"]
["検査希望日",null,null,null,null,null,null,null,null,null," 所在地"]
["第一希望",null,null,"月",null,"日","(　　)",null,"時","台"," TEL/FAX",null,null,null,null,null,"／"]
["第二希望",null,null,"月",null,"日","(　　)",null,"時","台"," 医師名"]
["患者基本情報"]
["フリガナ",null,null,null,null,null,null,"性別",null,"男","保険情報",null,null,null,"健康保険証",null,"／","交通事故",null,null,"労災"]
["患者\n氏名",null,null,null,null,null,null,null,null,"女","保険証番号"]
["生年\n月日",null,null,"大正",null,"昭和",null,"平成",null,"令和","被保険者証\n記号・番号"]
[null,null,null,"年",null,"月",null,"日",null,"才","被保険者との続柄",null,null,null,null,"本人",null,"家族","／","事故・労災"]
["住所",null,null,null,null,null,null,null,null,null,"公費負担番号"]
["ＴＥＬ",null,null,null,null,null,null,null,null,null,"公費負担医療の\n受給者番号"]
[null,null,null,null,null,null,null,null,null,null,"体重",null,null,null,"㎏","負担割合",null,null,"割","負担"]
["検査依頼／診療情報"]
["造影検査\nの有無",null,null,"単純のみ",null,null,null,null,null,null,null,null,"画像郵送方法",null,null,"後日郵送（1週間以内）"]
[null,null,null,"造影検査",null,"Cr：",null,null,"eGFR：",null,null,null,null,null,null,"当日患者渡し * 読影レポートは後日郵送"]
["検査項目",null,"頭　部",null,"頭部MRA・頚部MRA",null,null,null,null,null,"腹部／\n骨盤部",null,"肝・胆・膵（MRCP）",null,null,null,null,"腎臓"]
[null,null,null,null,"VSRAD",null,null,null,"眼窩",null,null,null,"膀胱",null,"前立腺",null,null,"婦人科（子宮・卵巣）"]
[null,null,null,null,"副鼻腔",null,null,null,"頚部",null,"脊　椎",null,"頸椎",null,null,"胸椎",null,null,"腰椎"]
[null,null,null,null,"その他（",null,null,null,null,"）",null,null,"胸腰椎移行部（第8胸椎～第5腰椎まで）"]
[null,null,"関　節　／　他","　肩関節（",null,null,"右",null,"左　　）",null,null,null,"　股関節（",null,null,"右",null,"左　　）"]
[null,null,null,"　肘関節（",null,null,"右",null,"左　　）",null,null,null,"　膝関節（",null,null,"右",null,"左　　）"]
[null,null,null,"　手関節（",null,null,"右",null,"左　　）",null,null,null,"　足関節（",null,null,"右",null,"左　　）"]
[null,null,null,"　手　　　（",null,null,"右",null,"左　　）",null,null,null,"　足　　　（",null,null,"右",null,"左　　）"]
[null,null,null,null,"上肢その他（",null,null,null,null,null,null,"）",null,"下肢その他（",null,null,null,null,null,null,"）"]
["【検査目的】"]
[]
["【臨床診断】"]
[]
["【撮影指示 等】"]
[]
[]
[]
["地域医療連携室　連絡先\n《　ＦＡＸ　０４３－４８６－１８０７　》\n《　ＴＥＬ　０４３－４８６－５５１１　》\nお問い合わせ　月-金　8:30-17:00　／　土　8:30-12:00　（年末年始・祝日除く）"]

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["【核医学検査】　検査依頼書/診療情報提供書"]
["検査申込日",null,null,null,null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null," 医療機関名"]
["検査希望日",null,null,null,null,null,null,null,null,null," 所在地"]
["第一希望",null,null,"月",null,"日","(　　)",null,"時","台"," TEL/FAX",null,null,null,null,null,"／"]
["第二希望",null,null,"月",null,"日","(　　)",null,"時","台"," 医師名"]
["患者基本情報"]
["フリガナ",null,null,null,null,null,null,"性別",null,"男","保険情報",null,null,null,"健康保険証",null,"／","交通事故",null,null,"労災"]
["患者\n氏名",null,null,null,null,null,null,null,null,"女","保険証番号"]
["生年\n月日",null,null,"大正",null,"昭和",null,"平成",null,"令和","被保険者証\n記号・番号"]
[null,null,null,"年",null,"月",null,"日",null,"才","被保険者との続柄",null,null,null,null,"本人",null,"家族","／","事故・労災"]
["住所",null,null,null,null,null,null,null,null,null,"公費負担番号"]
["ＴＥＬ",null,null,null,null,null,null,null,null,null,"公費負担医療の\n受給者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"負担割合",null,null,"割","負担"]
["検査依頼／診療情報"]
["画像郵送方法",null,null,"後日郵送（1週間以内）"]
[null,null,null,"当日患者渡し * 読影レポートは後日郵送"]
["検査項目",null,null,"骨シンチ"]
[null,null,null,"脳シンチ　ＤＡＴ",null,null,null,null,null,null,null,null,"ＭＩＢＧシンチ"]
[null,null,null,"　併用注意薬（",null,null,null,"有",null,"無","）",null,"　併用注意薬（",null,null,null,"有",null,"無","）","ﾁｪｯｸ外し"]
[null,null,null,"　薬剤名（",null,null,null,null,null,null,"）",null,"　薬剤名（",null,null,null,null,null,null,"）"]
[null,null,null,"　30分仰臥位（",null,null,null,"可",null,"不可","）",null,"　15分仰臥位（",null,null,null,"可",null,"不可","）","ﾁｪｯｸ外し"]
[null,null,null,"脳血流シンチ　ＩＭＰ"]
[null,null,null,"　30分仰臥位（",null,null,null,"可",null,"不可","）","※　全て指定の仰臥位時間が保てなければ検査実施できません",null,null,null,null,null,null,null,null,"ﾁｪｯｸ外し"]
["【検査目的】"]
[]
["【臨床診断】"]
[]
["【撮影指示 等】"]
[]
[]
[]
["地域医療連携室　連絡先\n《　ＦＡＸ　０４３－４８６－１８０７　》\n《　ＴＥＬ　０４３－４８６－５５１１　》\nお問い合わせ　月-金　8:30-17:00　／　土　8:30-12:00　（年末年始・祝日除く）"]