To: scheduling@marketing.flrad.com	
Subject: Appointment Request
                                              
Your e-mail address: [email]
Your phone number: [Phone]
First Name: [ContactFirst]
Last Name: [ContactLast]
Relationship: [Relationship]
Patients first name: [PatientName]
Patients last name: [LastName]
Patients date of birth: [DOB]
Daytime phone number for the patient: [DayPhone]
Evening phone number for the patient: [EvePhone]
Referring Physician: [Referring]
Diagnosis code for this exam request: [Diagnosis]
Exam is being requested: [Reason]
Monday: [Mon]
Tuesday: [Tues]
Wednesday: [Wed]
Thursday:[Thur]
Friday: [Fri]
Saturday: [Sat]
AM-PM: [AMPM]
Location: [Location]
Additional comments: [Comments]