Regulation 64

the following information about the licensee issuing the report:

the licensee’s name and the business name (if different from the licensee’s name) by which the licensee provides the nuclear medicine service;

the licensee’s address;

all of the following identifying information:

the patient’s name;

the patient’s identification number or passport number;

where the information in sub‑paragraphs (i) and (ii) is not known to the licensee — any other information identifying the patient;

the address of the approved permanent premises at which the applicable test is conducted;

the date the applicable test is conducted;

the name of the applicable requestor;

the description and findings of the applicable test;

the date the report is issued;

the name and signature (including an electronic signature) of the qualified person certifying the results, or interpreting and reporting the findings, of the applicable test.