Electronic Update Request For Service - Interventional Radiography / Angiography

Electronic Update Request - Service Profile : Interventional Radiography / Angiography

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Please include inclusive language when making changes.

Official Name

Alternate Names


IR (Acronym)
Angio (Other)
Diagnostic Imaging (Other)
Interventional Radiography (Preferred)
DI (Acronym)

Organization

Affiliation/Partners

Short Description

Long Service Description

Key Providers May Include Check NOC List

Languages

Languages Note

Waiting Period

Waiting Time

Waiting Unit

Waiting Period Note

Referral

Referral Note

Fees

Fees Note

Fee Reduction

Fee Reduction Note

Eligibility

Eligibility Note

Eligibility Note cannot be blank since the eligibility is set to Yes.

Access

Access Note

Contact Name *

Please enter contact name.

Title

Telephone *

Please provide a phone number or email.

Email *

Please provide a valid email.

Comments

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