Transcription of Computed Tomography (CT) Request - Alberta Health …
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Computed Tomography (CT) Request - Alberta Health …
<Fax to Diagnostic Imaging; fax numbers listed <Urgent/Emergent requests must bediscussed by direct consultation witha radiologistCurrent Patient ConditionDepartment Use OnlyDate format: yyyy-Mon-dd- Time format: hh:mmDate Received Time ReceivedDate of AppointmentTime of AppointmentMore info required oNo oYes Explain:Protocol: IV Contrast oNo oYesOral Contrast oNo oYesPriority oOP1 oOP2 oOP3 oOP4, Specify date:Clerk InitialRadiologist NamePreferred Facility00033 (Rev2017-06)Relevant Previous Imaging StudiesLocationTypeDate(yyyy-Mon-dd)Attached copyoNo oYesRenal Insufficiency oNo oYes On Dialysis oNo oYes run days.
Computed Tomography (CT) Request Preferred Facility. Inpatient Location Patient Address: City Postal Code: Patient Phone Number (Cell # preferred) WCB Claim Number: Ordering Provider Name (last,first and middle) Provider Phone ... Computed, Tomography, (CT), Request, 00033, form Created Date:
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