Page 1 of 2 GENERAL INQUIRIES: 416-323-6080 ULTRASOUND: 2nd Floor Fax: 416.323.6311 Tel: 416.323.6400 ext.4829 BREAST IMAGING: 5th Floor Fax: 416.323.6316 Tel: 416.323.6400 ext. 3080 GENERAL RADIOLOGY: 2nd Floor Fax: 416.323.6316 Tel: 416.323.6400 ext. 3220 DEPARTMENT OF MEDICAL IMAGING Form number F-5035 (2-2020) 76 Grenville Street, Toronto, Ontario M5S 1B2 BREAST IMAGING - By appointment only □ Mammogram: Bil R L □ Breast Ultrasound: Bil R L □ Axilla Ultrasound: Bil R L □ Stereotactic Core BX: Bil R L □ U/S Core BX: Bil R L □ Fine Needle Aspiration Bil R L □ Galactography: Bil R L □ Consultation/Review of Outside Films □ Pre-Op Localization Previous Mammogram & Ultrasound □ Yes □ No When & Where: ____________________ Surgery Date and Time: ________________ CLINICAL INFORMATION: PHYSICIAN’S SIGNATURE: ____________________________________ BILLING NUMBER: ___________________ F5035 PLEASE SEE PREPARATION ON REVERSE SIDE INCOMPLETE REQUISITIONS WILL CAUSE A DELAY IN SERVICE GENERAL ULTRASOUND □ Abdomen (gallbladder, pancreas, spleen, liver, kidneys, aorta) □ Abdomen/pelvis complete □ KUB (kidneys, ureters, urinary bladder) □ Hernia only FEMALE PELVIS □ Pelvis □ Transvaginal □ Sonohysterogram MALE PELVIS □ Pelvis (transabdominal, includes bladder, prostate seminal vesicles) OBSTETRICAL □ Dating □ NT □ Anatomic □ NT (11+3-13+3 weeks) + Anatomic (19-20 weeks) □ Biophysical Profile □ Assessment of fetal growth □ Other: ________________ VASCULAR □ Leg Doppler (Venous only) Bil R L □ Arm Doppler (Venous only) Bil R L MSK □ __________ __________ SMALL PARTS □ Face □ Thyroid □ Neck □ Chest □ Groin □ Scrotum □ Soft tissue/ lump ULTRASOUND Arrive at least 15 minutes before your appointment and bring this form and your OHIP card. If you arrive late, you may be rebooked at another time and date. Patient’s last name Patient’s first name Address Date of birth DD / MM / YYYY City Province Postal Code Phone Mobile Health card number Version code Physician Address Phone number Fax number CC reports to Date Clinical History (MANDATORY) □ STAT □ VERBAL Contact # ___________________________________ X-RAY ABDOMEN: HEAD & NECK: CHEST: SPINE & PELVIC: LOWER EXTREMITIES: UPPER EXTREMITIES: □ Single □ 2 Views Neck or Soft Tissues □ Orbits pre MRI □ Other: __________ __________________ __________________ □ Chest PA & LAT □ Chest PA-Immigration □ Ribs R L Bil □ Sterno-Clavicular JTS. □ Sternum □ Other: ______________ ______________________ □ Cervical Spine □ Thoracic Spine □ Lumbar Spine □ Sacrum □ Coccyx □ Sl Joint □ Pelvis □ Pelvis & Hips □ 3 Foot Spine □ Skeletal Survey □ Other: ________ □ □ Clavicle □ □ A.C. Joints □ □ Shoulder □ □ Scapula □ □ Humerus □ □ Elbow □ □ Forearm □ □ Wrist □ □ Scaphoid □ □ Hand □ □ Digit 1 2 3 4 5 □ □ Hip □ □ Femur □ □ Knee □ □ Tib, & Fib □ □ Ankle □ □ Foot □ □ Toe 1 2 3 4 5 □ □ Calcaneus □ □ 3 feet or 4 feet leg □ □ Other: _________ _____________________ R L R L CPSO number: Date: _______________ DD/MM/YYYY