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REQUISITION

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									                                                                REQUISITION
                                                                CENTRAL BOOKINGS Ph 780-450-1500 Toll Free 1-800-355-1755 Fax 780-450-9551
                                                                Patients who miss their appointment and fail to cancel 24 hours prior to their exam may be charged a $25.00 fee



   NAME: _______________________________________________________________
   ADDRESS: ___________________________________________________________                                                                     Date: ____________________________________________
   PHONE: RES: ________________________                                     BUS: _________________________                                  Time: ___________________________________________
                      mm / dd / yyyy
   DATE OF BIRTH: ______________________                                    AGE: _____                  MALE           FEMALE               Clinic Location: ___________________________________
   INSURANCE #: _______________________ WCB (                                              ) OTHER: ____________

   SIGNIFICANT HISTORY / CLINICAL DIAGNOSIS
                                                                                                                                                                                             Tech Initials _____________
                                                                                                                                                                                             Room # ________________
                                                                                                                                                                                             Fluoro _________________

       X-RAY            ALL SITES (NO APPOINTMENT NECESSARY)                       FLUORO               HYS CENTRE TAWA CENTRE CENTURY PARK                MSK INJECTIONS HY                                 L        CENTURY PARK

   EXAMS REQUESTED:                                                                S&D                                                                     Arthrogram or               Injection
                                                                                   S & D Small bowel follow through                                 Site: _________________________
                                                                                   Small bowel follow through only                                            (eg. hip, facet, etc.)
                                                                                   Barium Enema                                                            Left          Right               Both

       ULTRASOUND                                                         TAW                                  RY PARK

       Abdomen               Bladder                            Scrotal                                  Routine Pregnancy                                                 3rd T Obstetric ___ BPP (fetal wt & score)
       Pelvis                Thyroid                            Inguinal Hernia                          Twin Pregnancy                                                    3rd T Obstetric ___ BPP score/AFI only
       Renal                 Breast___rt___lt                   Early Obstetric (<12 wk)                 3rd T Obstetric ___ complete (fetal wt)                           3rd T Obstetric ___ position only
                                                                                                                                                                           3rd T Obstetric ___ cervical length only
   DOPPLER ULTRASOUND
     Carotid Arteries Echocardiogram                                            Venous doppler of legs (R/O Acute DVT) rt___lt___                                          Other: _________________________

       ENDOVENOUS LASER THERAPY (EVLT) – (Century Park only)

       NUCLEAR MEDICINE                                                                 TAW                                    RY PARK

       Billary Scan (HIDA) (approx 2 hours)                                                                          Myocardial Perfusion Imaging with Ejection Fraction (MIBI)
       Bone Scan (15 min., return approx 2-3 hours later for 1 hour)                                                 (College Plaza, Hys Centre, Summit Centre, Century Park)
       Gallium Scan (3 separate days)                                                                                Meckel’s Scan (approx. 1 hour)
       Gated Cardiac Scan (approx. 1 hour)                                                                           Renal Imaging                         Captopril           Diuretic              Other (approx. 1 hr)

       MAMMOGRAPHY                                                                                                                             AW                                  RY PARK

       Screening (No Signs or Symptoms)
       Diagnostic (Provide History)                                                                 R                            L
       Core Biopsy (Hys Centre Only)

       BONE DENSITOMETRY                                                                      TAW                                    RY PARK

       Spine and Hip                                                                                                 Thoracic and Lumbar Spine Correlative X-Rays

       MAGNETIC RESONANCE IMAGING                                                                                  RY PARK Requires separate requisition

   DATE OF L.M.P. __________                                   FAX REPORT TO # _________________________                                            PRACTITIONER’S NAME: ________________________
   PREGNANT?                YES           NO                   SEND IMAGES TO: _________________________                                            PRACTITIONER’S ADDRESS: ____________________
   PATIENT’S SIGNATURE:                                        COPY OF REPORTS TO: ____________________                                             _____________________________________________
   ________________________                            ADDRESS: __________________________________                                                  SIGNATURE: __________________________________

         CENTRAL                          UNIVERSITY AREA                              SOUTHEAST                               SOUTHWEST                                  ST. ALBERT                    MIC ADMINISTRATION

HYS MEDICAL CENTRE                    COLLEGE PLAZA                             TAWA CENTRE                            CENTURY PARK                               SUMMIT CENTRE              MAIN FLOOR, HYS CENTRE
#202, 11010 - 101 ST NW               8TH FLOOR, 8215 - 112 ST NW               3017 - 66 ST NW                        #201, 2377 - 111 ST NW                     #102, 200 - BOUDREAU RD    11010 - 101 ST NW
Ph 780-450-1500 / 1-800-355-1755      Ph 780-450-1500 / 1-800-355-1755          Ph 780-450-1500 / 1-800-355-1755       Ph 780-450-1500 / 1-800-355-1755                                      EDMONTON, AB
                                                                                                                                                                  Ph 780-450-1500 / 1-800-355-1755
Fax 780-424-7780                      Fax 780-439-9977                          Fax 780-461-7527                       Fax 780-461-8524                           Fax 780-459-2376           Ph 780-426-1121
Breast Imaging Centre                                                           Open Saturdays 10:00am - 5:00pm        Open Saturdays 9:00am - 5:00pm                                        Fax 780-425-5979
#203, 11010 - 101 ST NW               MRI COLLEGE PLAZA                         (X-Ray Only)                           (X-Ray Only)                               GRANDIN X-RAY (X-ray Only) Bookings 780-450-1500
                                      7TH FLOOR, 8215 - 112 ST NW                                                                                                 1 ST. ANNE ST
ALLIN CLINIC (X-ray Only)             Ph 780-433-1120                                                                  MRI CENTURY PARK                           Ph 780-450-1500
B1, 10155 - 120 ST NW                 Fax 780-433-7286
                                      Toll Free 1-888-880-1121
                                                                                                                       Ph 780-432-4131                            Fax 780-458-9096                       www.mic.ca
Ph 780-450-1500                                                                                                        Fax 780-432-4181
Fax 780-488-0238
                                                                          PLEASE INFORM TECHNOLOGIST IF THERE IS A CHANCE YOU MAY BE PREGNANT
These examinations by appointment only. Please be on time. If you are late or not properly prepared you may have to rebook. Phone if
you are unable to keep the appointment. When making appointment, please notify us if the patient is DIABETIC and book early in the day.

  FLUOROSCOPY                         TW             RY

  If there is any chance of pregnancy, the exam should be postponed until menses or the 10 days thereafter.
     ESOPHAGUS, STOMACH AND DUODENUM and/or SMALL BOWEL
     Do not eat or drink anything after midnight the night before your examination (if your exam is scheduled after 1:00 p.m., you may have 1 slice of dry
     toast and 1 cup of clear liquid prior to 7:30 a.m.). Small bowel - may take longer than 3 hours.
     COLON (BARIUM ENEMA)
     48 hours prior to the examination, follow a diet of unrestricted amounts of clear liquids only such as water, clear juice, consomme, tea, coffee, or
     jello and then continue with instructions below:
     Day prior to examination (the following drugs should be obtained from your pharmacy):
     A diet of unrestricted amounts of clear liquids only such as water, clear juice, consomme, tea, coffee, jello;
     At 4:00 p.m. take 4 tablespoons of Milk of Magnesia;
     At 5:00 p.m. drink one bottle of Magnesium Citrate laxative;
     At 7:00 p.m. take 3 Dulcolax tablets (5 mg);
     Continue with clear liquid diet the rest of the day.
     Day of the colon examination:
     Nothing to eat until the examination is completed. Drink clear fluids as required.
     *For these fluoro examinations only, DIABETICS should consult their physicians regarding possible stoppage or reduction of Insulin
     while fasting or on “clear liquids only” diet.

  ULTRASOUND                                   TW                         RY

     ABDOMEN ULTRASOUND
     Eat only fat-free foods the evening prior to your examination. Do not eat anything after midnight the night before your examination. If your
     examination is booked for the afternoon, you may eat a slice of dry toast and drink clear liquids up until 8:00 a.m. You may continue to drink plain
     water until 3 hours prior to the examination. Do not chew gum prior to or during exam.
     PELVIC, OBSTETRICAL, BPP OR RENAL
     Empty your bladder (if necessary) 90 minutes prior to the examination. After voiding, drink four glasses (1 litre total) of water or clear juice - finish
     drinking the full amount at least one hour prior to the examination. Do not empty your bladder again prior to the examination. The examination may
     not be done if your bladder is not full. You may continue to eat.
     ABDOMEN AND PELVIC ULTRASOUND
     Eat only fat-free food the evening prior to your examination. Do not eat anything after midnight the night before your examination. Empty your
     bladder (if necessary) 90 minutes prior to the examination. Following this, drink four glasses (1 litre total) of water at one sitting. Do not empty your
     bladder again prior to the examination. This examination cannot be done if your bladder is not full.
     *All other ultrasound examinations listed do not require patient preparation.

  NUCLEAR MEDICINE                                        TW                        RY

  If there is any chance of pregnancy, the exam should be postponed until menses or the 10 days thereafter.
  If you are breast feeding, please talk to your physician or the technologist prior to the examination.
     BONE SCAN: Bring most recent relevant x-rays for bone scan.
     BILIARY SCAN: Nothing to eat or drink after midnight.
     RENAL SCAN: (Diuretic, Others): Drink a minimum of four cups of fluids prior to examination. Examination time may range from 45 minutes to 2 hours.
     RENAL SCAN: CAPTOPRIL: Patient off ACE inhibitors for 48 hours. No breakfast. Drink at least four cups of fluids prior to examination.
     Take 50 mg of CAPTOPRIL 1 hour prior to examination as prescribed by your own physician.
     GALLIUM SCAN: No preparation prior to the injection. Involved 3 separate days, the first for injection, two days later for images which take 45 minutes.
     MECKEL’S SCAN: Starting at 8:00 a.m., 1 day prior to exam, take 150 mg Zantac every 4 hours (total 4 doses). Nothing to eat or drink after
     midnight. Total examination time is 1 hour.
     The following Scans Require No Preparation: Rest Gated Cardiac Scan and Salivary Scan

  BONE MINERAL DENSITOMETRY                                                    TW                       RY
                                                                               TW                       RY
  No preparation required.

  MAMMOGRAPHY                                                  TW                        RY

  Do not use perfume, deodorant, antiperspirant or talcum before the examination. Premenstrual breast tenderness - you may delay booking until
  tenderness has subsided. Wear a two piece outfit. At the time of booking advise where previous mammogram was done and if possible allow
  appropriate time for films to arrive before appointment date.


  *ALL EXAMINATIONS*                   PLEASE BRING YOUR HEALTH INSURANCE CARD AND THIS SIGNED REQUEST.

  This form indicates the type of examination your doctor wants us to perform and any other pertinent information. Examinations can take
  longer than anticipated. Please be punctual and allow plenty of time. If your doctor’s office has not made an appointment for you, please
  telephone and arrange one. If you are unable to keep your appointment, telephone to cancel it. Inform us of any limitation of mobility, or if
  you are diabetic.

								
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