Ct/mri Mississauga Request For Examination Form

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CT/MRI MISSISSAUGA REQUEST FOR EXAMINATION
Tel: 1-844-731-1817 Fax: 905-568-0941
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Ajax
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Mississauga
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CT
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MRI
Please Indicate area to be examined:
Patient Information
Referring Physician Information - Must include signature
First Name
Last Name
Name
Address
Home Phone
Other Phone
Phone
Fax
|
/
/
/
/
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MM
DD
YYYY
MM
DD
YYYY
Health Card Number
Sex
Date of Birth
Date
PHYSICIANS SIGNATURE
THIRD PARTY INFORMATION
Tel: 1-844-731-1817 Fax: 905-426-3741
WSIB Claim #
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Is this a WSIB Examination? Yes
No
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/
MM
DD
YYYY
Date of Accident:
Company Name
Contract#
Phone#
Fax#
Significant Clinical History/ Clinical Diagnosis:
FOR PATIENTS OVER 60 YEARS OF AGE
Previous Relevant Exams:
When
Where
#
/
/
Most recent creatinine level within 3 months:
MM
DD
YYYY
Date:
NONE
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MRI
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PT taking Metformin or Glucophage:
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Yes
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No
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CT
Previous contrast reaction:
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Yes
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No
X-ray
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Please list any allergies:
Ultrasound
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MRI PATIENT SCREENING
(Must be completed with patient)
Angiogram
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Yes/No
Nuclear Medicine
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Ever worked with metal (grinding, welding, etc.)
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Arthrography
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Previous eye injury with metal (Please provide orbit x-ray)
Please fax all previous reports with requisition.
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Pacemaker
Please list ALL SURGERY (specify date and type):
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Cochlear or Ear implants
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Eye surgery or implants
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Cerebral Aneurysm clips
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Heart valve replacement
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Intravascular coils, filters, stents
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Joint replacement/prothesis, artificial limbs, pins, screws, plates
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Surgical clips, staples
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Neurostimulators, implanted mechanical devices, pumps, ports
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Shrapnel, bullets, other metal
Patient Signature:
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Hearing Aid
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Piercing, tattoos, permanent make-up
Date
/
/
Technologist
MM
DD
YYYY
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Pregnant
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Internal birth control device
Imaging Protocol (Radiologist Use)
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Claustrophobia (if sedation required, to be provided by physician)
-Appropriate transportation to be arranged by patient.
If YES to any, please SPECIFY (date, type, implant model)
IMG-CTMRI-01

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