Breast Ultrasound

Patient’s Last Name First Name Phone # Sex M F

NO APPOINTMENT NEEDED FOR X-RAYS

Referring Physician:

M.D.

REQUEST FOR STAT CASE :

VERBAL - TEL:

FAX:

CC:

CLINICAL INFORMATION

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ULTRASOUND - (Appointment Recommended But Not Always Needed)

X-RAY – (No appointment Required)

491 Lawrence Ave, WestLower level TwoToronto, ON M5M 1C7Tel : 416-781-9375Fax : 416-781-7175Email : info@cdimaging.caWeb : www.cdimaging.ca

HOURS OF OPERATION

Mon - Fri : 8 am - 5 pm Sat-Sun : 9 am - 2 pm

Tel : 416-781-9375Fax : 416-781-7175

Mammography

High Risk Routine Base Line

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CAR AccreditedOBSP Accredited

WOMEN’S IMAGING

PREGNANCY RELEASE FORM

I declare, to the best of my knowledge that I am not currently pregnant.

Patient’s Signature

FULLY DIGITALIZED FACILITY

Before ordering X-Rays, make sure female patients are not pregnant.Note : This requisition form can be taken to any licensed facility providing healthcare services including hospital and IHFs, such as those listed on the IHF Program website:http://www.health.gov.on.ca/en/public/programs/ihf/facilities.aspx.

BONE MINERAL DENSITOMETRY

3 Year follow- up

(By Appointment )

__________________________________________Date and location of previous scan

GENERALAbdomenFemale PelvisTransvaginalMale PelvisTransrectal/ProstateKidneys and BladderFollicle MonitoringOthers ___________

SMALL PARTSThyroidParotidSubmandibularNeckTesticular/ScrotalGroin/InguinalSoft Tissue/LumpOthers ____________

OBSTETRICAL

Same DayAppointment forUrgent Ultrasound

1ST Trimester IPS/NT2nd/3rd Trimester/Hight RiskAnatomy Scan (18-20 wks)BPP/EFC

Placenta EvaluationR/O Ectopic3D/4D Ultrasound of baby (Not covered by Ohip)

DLNMP ___________

UrgentNon-Urgent

MandibleTM JointsAdenoidsSoft Tissue NeckOrbits (FB)

ABDOMENKUBAcute (2 Views)

SKELETAL SURVEYArthritic Metastatic

UPPER EXTREMITIESShoulderClavicleAC JointsScapulaHumerusElbowForearmWristHandDigits

LOWER EXTREMITIES HipFemurKneeTibia & Fibula AnkleFootCalcaneusToes

CHESTChest PA & LAT Sternum Sternoclavicular Joints Ribs Chest PA (Immigration)

SPINE & PELVIS Cervical Spine Thoracic Spine Lumbo - Sacral Sacrum & Coccyx Pelvis Pelvis & HipsSI Joints

HEAD & NECKSkullSinusesFacial BonesNasal Bone

Health Card No: Version Code: Date of Birth :

MUSCULOSKELETAL L□□R Shoulder L□□R Elbow LO DR Wrist L□□R Hand L□□R Hip L□□R Knee L□□R Ankle/Foot L□□R Arm L□□R Forearm L□□R Thigh L□□R Hamstrings L□□R Calf L□□R Achilles Tendon L□□R Plantar Fascia L□□R Others

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Routine OBSP

Breast Implants Breast Implants RightLeft

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