3045 Baseline RoadNepean, OntarioK2H 8P4
C.T./MRI BOOKINGS ONLY
NUCLEAR BOOKINGS ONLY
SPECIALIZED IMAGING REFERRAL FORM
(C.T. SCAN, MRI, NUCLEAR MEDICINE)
Please complete all sections and SIGN.
Requisition is required to preform any diagnostic test
Referral forms with insufficient clinical information will be returned
MRI PATIENT SCREENING
C.T. / MRI REQUESTS
(must be completed to be booked)
Max weight 170kg (162cm girth)
Max weight 170kg
Max weight 158kg
The following information must be provided prior to test being scheduled
Protocol (Dep use only)
Allergy to Iodine
Diabetic on Metformin/Glucophage/Avandia Met
Is the patient of African Descent?
Glomerular Filtration Rate (GFR)
IMPORTANT PATIENT INFORMATION ON OTHER SIDE
(CLINICAL INFORMATION IS MANDATORY)
Clinical Information /Reason for test:
Referring Physician: PLEASE PRINT
Copy report to Physician: PLEASE PRINT
Thank you for allowing us to service your Diagnostic health care needs!
IMPORTANT PATIENT PREPARATION
If a patient is more than 15 minutes late for their appointment they may be rebooked.
Patients that do not follow test preparation or fail to cancel their appointment at least
24 hours prior to test may be charged $50.00 fee.
4 hrs before test
*Allergy to Iodine:
6 hours, starting 24 hours before exam.
48 hours prior and 48 hours after exam.
In-Patient: Please follow separate 48 hour
test. If not oral start contrast 15 minutes
* All CT Scan
appointments : Please contact us if your patient weighs more than 375 lbs.
Fasting (4-6 hrs) before test
For a Cardiac StressTest
: No caffeine 48 hrs prior to test, fast 4 hours before test.
Follow instructions given by our Patient Scheduling Department.Note:
For a Thyroid Scan,
the patient cannot have had X-ray dye and or Contrast media within the past six weeks.
Please contact the imaging booking department if you answered yes to any of the MRI screeningquestions before you send your referral. More information and O.R. Reports may be requiredto expedite the booking procedure.
All patients will need to complete a second MRI Patient Screening Form prior to MRI exam.
Most MRI examinations require no special preparation. Any test requiring will be explained atthe time of booking your appointment.
Abdomen & Pelvis MRI’s : The patient needs to fast 4 hrs prior to test.
Please contact us prior to booking test if the patient weighs more than 375 lbs,
FOR ANY PREPARATION OR BOOKING QUESTIONS CONTACT ( 721-4711)
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