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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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