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