Kidneys & Pelvis (Pre/Post void Bladder vol.)
Patient Name:
DOB: F
Health card:
Tel:
M
Please affix label here.
DIAGNOSTIC IMAGING REQUISITION
6175 Hwy # 7 • Units 19 - 22 • Vaughan, ON • L4H 0P6 Tel: 416.297.8362 • Fax: 416.840.8434
Clinical History:YOUR APPOINTMENT
DATE:
TIME:
STAT CASE
VERBAL RESULTS
CONTACT NUMBER:
CHEST
HEAD & NECK UPPER EXTREMITIES LOWER EXTREMITIES
X-RAY – NO APPOINTMENT NECESSARY
Chest (PA + Lateral)Ribs & Chest PA SternumSterno-Clavicular Joints
Skull
Sinuses
Facial Bones
Nasal Bones
Mandible
T.M. Joints
Mastoids
Orbits
Adenoids/Soft Tissue
Pituitary Fossa
IA Meati
Cervical Spine
Thoracic Spine
Scoliosis Series
Lumbo-Sacral Spine
L/S Spine, Pelvis, & S.I. Joints
Sacrum & Coccyx
S.I. Joints
Pelvis
Pelvis and Hips
SPINE & PELVIS
Shoulder
Clavicle
A.C. Joints
Scapula
Humerus
Elbow
Forearm
Wrist
Hand
Hand & Wrist
Scaphoid
Finger No. 1 2 3 4 5
Baseline Follow Up
Low Risk High Risk (yearly)
Date of Previous Scan
BONE DENSITOMETRY
Referred By:
OHIP Provider ID #:
Copy to:
BY APPOINTMENT ONLY
Abdomen - Complete
GENERAL ULTRASOUND
Dating ( < 16 weeks )
OBSTETRICAL ULTRASOUND
Routine ( >17 weeks )
Other:
Arterial legs (includes ABI)
Arterial arms
Venous legs (DVT)
Venous arms (DVT)
Carotid & Vertebral
Aorta
Vascular Screen (Carotid, Aorta, and Legs)
VASCULAR ULTRASOUND
Inguinal Canal /Hernia
24 hr Ambulatory BP monitoring (Note $50 charge to patient)
CARDIOLOGY
Holter Monitoring
2-D Echocardiogram
ECG - No Appointment Necessary
24 hr 48 hr 72 hr 14 day holter/event
Exercise Treadmill Stress Test (GXT)
Stress - Echo
Myocardial Perfusion Imaging
Exercise Persantine (Patient unable to walk, LBBB, Pacemaker)
NUCLEAR CARDIOLOGY
Complete PFT + Spirometry
Exercise Oximetry / 6 Minute Walk Test
PULMONARY
Please Specify:
MUSCULOSKELETAL ULTRASOUND
Thyroid
SUPERFICIAL STRUCTURES ULTRASOUND
Breast
Other:
Other:
Other:
Testes / Scrotum
Female Pelvis
Transvaginal
Transabdominal
Male Pelvis
Transrectal (Prostate)(includes Kidney and Bladder)
Transabdominal(includes Bladder, Prostate, and Seminal Vesicles)
MUGA Scan - Ejection Fraction
DD/MM/YY LMP:
Neck Axillary
Signature RequiredPrint
Patient Signature
ABDOMEN
Plain Film (K.U.B)
Acute (3 Views)
SKELETAL SURVEY
Metastatic Series
Arthritic Series
Bone Age
Hip
Femur
Knee
Tibia & Fibula
Ankle
Ankle Inv. w/ Stress Views
Foot
Os Calcis
Toe No. 1 2 3 4 5
Pregnant
Please indicate lesion site on image
Diabetic Foot Screen (Risk Assessment)
N
427
407
50 27
7
400
IHCC -VDMC
Esso
Steeles Ave.
Finch Ave.
HolidayInnQueen St. E.
H EtobicokeGeneralHospital
7
6175 Hwy 7Units 19 -22
GETTING HERE: From Brampton:
• Take preferred route toward Highway 7/Queen Street East and take the 501/501A Züm Queen bus eastbound to Gore Road.
• Transfer* onto the YRT #77/77A (Highway 7) bus and take it to Highway 7 and Vaughan Valley Blvd. (stop #5691).
• Walk forward and cross the street toward the plaza directly across the RBC Bank / McDonald’s / Swiss Chalet.
*Brampton transfers are accepted on YRT buses.
From Vaughan:
• Take preferred route toward Highway 7 and take the YRT #77/77A (Highway 7) bus westbound to Highway 7 and Vaughan Valley Blvd. (stop #4141).
• Cross the street toward the plaza directly across the RBC Bank / McDonald’s / Swiss Chalet. From William Osler Health Centre (Etobicoke General Hospital):
• Walk toward the northwest corner of Highway 27 and Humber College Blvd. (the bus stop is behind the houses [stop #5119]).
• Take the YRT#7 (Martin Grove) bus northbound to Martin Grove Rd & Highway 7 (stop #3525).
• Cross the street and transfer onto the YRT #77/77A (Highway 7) bus westbound to Highway 7 and Vaughan Valley Blvd. (stop #4141).
• Cross the street toward the plaza directly across the RBC Bank / McDonald’s / Swiss Chalet.
This requisition form can be taken to any licensed facility providing healthcare services including hospitals and IHFs.
Patient Preparation Instructions Please remember to bring your Health Card and this requisition signed by a registered physician
If you would like to cancel / change your appointment, please notify our office at least 24 hours prior to your scheduled time
ULTRASOUNDAbdomen: We require that you have an empty stomachNo eating or drinking (smoking or chewing gum) 8 hours prior to the appointment Abdomen / Pelvis: No eating or drinking 8 hours prior to the appointmentDrink 1 litre of water 1 hour prior to the appointmentDO NOT EMPTY BLADDER AFTER DRINKING
Obstetrical / Pelvis: Drink 1 litre of water 1 hour prior to the appointmentDO NOT EMPTY BLADDER AFTER DRINKING
Prostate, Kidney, Bladder (Transrectal): Purchase a Fleet Enema from a pharmacy Follow the instructions in the package Take the Enema 2 hours prior to the appointmentDrink 1 litre of water 1 hour prior to the appointmentDO NOT EMPTY BLADDER AFTER DRINKING
Vascular Screening / AortaWe require that you have an empty stomachNo eating or drinking 8 hours prior to the appointment
Exercise Treadmill Stress Test (GXT)Wear comfortable shoes and clothing• Women should wear a bra preferably with no underwire• Do not wear a one-piece garment
Consult with your physician if it is ok to discontinue Beta-Blockers (Bisoprolol, Metoprolol, etc.) 48 hours prior to your exam
Consult with your physician if it is ok to discontinue Calcium Channel Blockers (Diltiazem, Verapamil, etc.) 24 hours prior to your exam
Stress EchocardiogramWear comfortable shoes and clothing (Please do not wear a one-piece garment)
Nuclear CardiologyThis test takes approximately 2 - 4 hours and you will receive an intravenous injection• Wear comfortable shoes and clothing for the exercise stress test• Women should wear a bra preferably with no underwire• Do not wear a one-piece garment• NO CAFFEINE 24 hours prior to the test • Refrain from any coffee, tea, soft drinks, chocolate beverages, energy drinks (even the decaffeinated varieties)• No Tylenol 2’s or 3’s for at least 48 hours prior to the test• Do not smoke for 2 hours before the test• Have only a light breakfast on the day of the test (toast and juice) and then no food or drink 4 hours prior to the test (2 hours if you're a diabetic) Water is allowed • Bring something to eat during the test• Bring a list of current medications• Do not apply cream, lotion, or powder to your skin
Myocardial Perfusion Imaging (Exercise)Discontinue beta blockers 48 hours prior to the exam with your doctor’s approvalInsulin-dependent diabetic patients should take their insulin with a light meal 3 hours prior to the exam
Myocardial Perfusion Imaging (Persantine)Discontinue theophylline derivatives 48 hours prior to the exam with your doctor’s approval Insulin-dependent diabetic patients should take their insulin with a light meal 3 hours prior to the exam
GENERAL X-RAY EXAMS: Walk-in appointments and no preparation requiredIf there is a possibility you may be pregnant please contact your physician prior to the X-Ray
Bone DensitometryNo Barium studies or Nuclear Medicine tests 1 week prior to the examDo not take calcium / vitamin supplements 24 hours prior to the examPlease wear a two-piece outfit with no metal zippers, buttons, or belt around the waist level, if possible
Pulmonary Function TestPlease avoid smoking on the day of your testDo not use bronchodilators on the day of your testPlease bring a list of current medications
Please bring a list of current medications to your appointment