Request For Examination (Page 2 of 2) in pdf

* Please bring your health card and this paper with you to your appointment.

Vancouver

North Delta

1144 Burrard St.

15300 105th Ave

Unit #270

Unit #3

5740 Cambie St.

8425 120th Street

Phone: 604-689-8925

Phone: 604-581-1101

Unit #44

Unit #104

Fax: 604-689-3364

Fax: 604-582-8520

Phone: 604-325-3244

Phone: 604-590-2211

(X)

(X/U/F)

Fax: 604-325-0136

Fax: 604-581-0405

Across from St. Paul’s Hospital

Across from Guilford

(X/U/F)

(X/U/M/F)

Shopping Centre

Across from Oakridge Mall

Delta Medical Arts Building

2728 Hastings Street East

Free Parking

Phone: 604-254-1687

Burnaby

1669 East Broadway

Fax: 604-254-1687

Unit #430

(X)

New Westminster

MRI Vancouver

Phone: 604-873-1846

Vancouver Health Centre

3997 Henning Drive

Fax: 604-873-6318

Free Parking

401-233 Nelson’s Cres.

Unit #103

(X/U/M)

Phone: 604-526-2466

Phone: 604-272-9797

At Commercial Dr. Skytrain Station

Fax: 604-521-5904

Surrey

Fax: 604-272-9710

(X)

(MRI)

2184 West Broadway

9656 King George Highway

At the Gilmore Skytrain Station

Unit #390

625 Fifth Ave.

Unit #102

Free Parking

Phone: 604-731-2200

Unit #B1

Phone: 604-581-4616

Fax: 604-736-9314

Phone: 604-522-6818

Fax: 604-582-9022

Coquitlam

(X)

Fax: 604-522-6810

(X/F)

Regent Medical Building

(X/U/F)

Close to Surrey

1015 Austin Avenue

Near Royal City Centre Mall

Memorial Hospital

888 West 8th Ave.

Unit #101

Free Parking

Phone: 604-937-5588

Unit #106

Fax: 604-936-8800

Phone: 604-879-7726

(X/U/F)

Fax: 604-879-7725

Across from Rona

(X/H)

Free Parking

Laurel Medical Centre

For additional locations across BC, visit

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@cmlhealthcare

PATIENT INSTRUCTIONS – PATIENTS MUST BRING THIS REQUISITION AND VALID HEALTH CARD

GENERAL: Ensure that you bring your current health insurance card. Please arrive 15 minutes before your appointment. Phone to cancel if unable to keep

booked appointment. Please notify reception if you are diabetic. Please arrange to leave your children at home or have supervision.

X-RAY, FLUOROSCOPY AND HYSTEROSALPINGOGRAM INSTRUCTIONS

ESOPHAGUS, UPPER G.I. WITH OR WITHOUT SMALL BOWEL EXAMINATION

• Stomach and Duodenum only: examination time 30 minutes to 1 hour.

• Stomach, Duodenum and Small Bowel: examination time 1 to 3 hours.

• Nothing to eat or drink after midnight the night before your appointment , which includes chewing gum, candies and smoking.

COLON

• 48 hours before your appointment you may have a light lunch and dinner.

• 24 hours before your appointment you may have clear fluids only.

• No solid food until after the examination is complete.

The day before your appointment:

• 4:00 pm – Drink the entire contents of a Citromag solution with a large glass of water (or take 60mls of castor oil at 10am).

• 5:00 pm – Take 2 Dulcolax tablets with a large glass of water.

• 10:00 pm – Insert one Dulcolax Suppository.

• You may drink water up until your appointment time. Prescription medications may be taken with water. A clean colon gives the best results and avoids the

need for re-examination.

• All barium exams – Barium may cause constipation. Plenty of fluids should be taken after the examination. In addition, a laxative should be taken after the

examination if there is any tendency to constipation.

HYSTEROSALPINGOGRAM

• Abstain from sexual intercourse from the first day of menstrual period until the examination has been completed. Examination time is approx. 30 min.

ULTRASOUND INSTRUCTIONS

ABDOMINAL

• Fasting for 12 hours prior to the test and fat free diet (no dairy products, meat, eggs or fried foods) for 24 hours (day before). Nothing by mouth until after

examination. Examination time is approx 30 min.

RENAL ONLY

• Drink 2 full glasses (16 oz.) of water 2 hours prior to examination, Do not void until after the examination.

PELVIC / OBSTETRICAL / BLADDER EXAMINATION

• A full bladder is essential for these examinations. Do not empty your bladder for two hours before your appointment. Drink 32 oz. (4 cups) of liquid except

milk. Please complete drinking your fluids at least 1 hour before your appointment time.

ABDOMINAL AND PELVIC (COMBINATION SCAN)

• Fat free diet (no dairy products, meat, eggs or fried foods) for 24 hours and fasting for 12 hours. Do not empty your bladder for two hours before your

appointment. Drink 32 oz. (4 cups) of liquid except milk. Please complete drinking your fluids at least 1 hour before your appointment time.

BREAST, THYROID, TESTES AND EXTREMITIES

• No preparation is required.