Request For Examination Form - Oxford Medical Imaging
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1
2REQUEST FOR EXAMINATION FORM
Multiple clinics in the GTA to serve you.
See reverse for a convenient location nearest you.
Appointment
DAY
MONTH
YEAR
Location
DIGITAL ULTRASOUND (By appointment only)
VASCULAR STUDIES
FEMALE PELVIS
Arrive at least 15 minutes before your appointment and bring this form and your OHIP card.
q Carotid arteries
q Woman’s Yearly Exam
q Renal arteries
q Pelvis
If you arrive late, you may be rebooked at another time and date.
(includes transvaginal
q Aorta
unless contraindicated)
Patient’s Last Name
Patient’s First Name
q Portal venous hypertension
MALE PELVIS
q Peripheral arterial legs
(ABI)
q Pelvis
(transabdominal,
q Peripheral arterial arms
Address
Date of Birth
includes bladder, prostate,
(DD | MM | YYYY)
q Peripheral venous legs
seminal vesicles)
(DVT)
mR mL mBil
q Prostate
(transrectal includes
City
Prov.
Postal Code
Phone #
Mobile #
q Peripheral venous arms
transabdominal)
(DVT)
mR mL mBil
US GUIDED PROCEDURES
q Varicose vein assessment
Health Card #
q Sonohysterogram
GENERAL ULTRASOUND
q Thyroid FNA biopsy
Referred By
q Abdomen
q Other FNA
q Abdomen/pelvis complete
Address
q US guided injection
q Abdomen/pelvis (KUB)
MUSCULOSKELETAL
Phone #
Fax #
SMALL PARTS
(Includes corresponding X-ray)
q Face
Physician’s Signature:
R
L
Bil
q Thyroid and neck
q q q Shoulder
q Neck
CC Reports to:
q q q Arm
q Breast
(mR mL mBil)
q q q Biceps
CPSO #:
Date:
q Chest
q q q Elbow
q Groin
(mR mL mBil)
q Testes/Scrotum
q q q Wrist
Clinical History
q STAT q VERBAL
Contact #
(REQUIRED)
q Ophthalmic
q q q Hand
q Soft tissue/lump
q q q Finger
q q q Hip
OBSTETRICAL
q Dating
q q q Thigh
q Combined NT + Anatomic
q q q Knee
q q q Popliteal fossa
(11–14 wks) + Anatomic (18–20 wks)
mNT
q q q Calf
mAnatomic
q q q Ankle
q NT
(11–14 wks)
q q q Achilles tendon
DIGITAL X-RAY
|
Walk-in appointments accepted
q Anatomic
(18–20 wks)
q q q Foot
q Fetal growth follow-up
CHEST
HEAD & NECK
UPPER EXTREMITIES
q q q Toe
q Biophysical profile
q Chest
q Soft tissue neck
(2 views)
R
L
Bil
q q q Plantar fascia
q Twin Series
1
q q q Shoulder
q Ribs & chest P.A.
q Skull
q q q Other
q High Risk Twin Series
2
q q q Clavicle
q Sinuses
(mR mL mBil)
q No X-ray req’d
q Follicular monitoring
q q q Sternoclavicular joints
q Sternum
q Orbits for MRI
q q q A.C. joint
q Chest visa
q Facial bones
DIGITAL MAMMOGRAPHY (FFDM)
q q q Scapula
q Nose
ABDOMEN
By appointment only. See reverse for preparatory
q q q Humerus
q Mandible
q Plain film
(KUB 1 view)
instructions and locations.
q q q Elbow
q T.M. joints
q Acute
+ PA chest
(2 views)
1
Lesion
(please indicate site on image)
q q q Forearm
q Adenoids
SPINE & PELVIS
q q q Wrist
q Mastoids
Previous: qYes qNo
q Cervical spine
q q q Scaphoid
SKELETAL SURVEY
q Thoracic spine
Where:
q q q Hand
q Metastatic series
q Lumbar (L/S) spine
Right
Left
q q q Fingers
# 1 2 3 4 5
q Arthritic series
When:
q L/S spine, pelvis & S.I. joints
q Bone age
q Sacrum & coccyx
Clinical info:
LOWER EXTREMITIES
q S.I. joints
WOMAN’S YEARLY EXAM
BONE MINERAL DENSITOMETRY (BMD)
q Pelvis
R
L
Bil
q Includes all listed below
By appointment only. (No contrast or radioactive exam the
q q q Hip
q q q Femur
previous week).
• US female pelvis
q q q Knee
• US abdomen
q Baseline
qLow risk
qHigh risk
3
(1
st
BMD)
(Every year)
q q q Tib. & fib.
• US thyroid
Previous
: qYes qNo
q q q Ankle
(required)
• US breast
q q q Foot
Where:
When:
• Digital mammogram
q q q Calcaneus
• BMD
(if applicable)
Indication:
q q q Toes
# 1 2 3 4 5
Y O U R H E A L T H I S O U R I M A G E
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