Transcription of Ultrasound Request Form - Alberta Health Services
1 Last Name (Legal) First Name (Legal). Ultrasound Request Preferred Name Last First DOB(dd-Mon-yyyy). n ALL fields must be completed in order to process Request PHN ULI Same as PHN MRN. n Fax to Diagnostic Imaging; fax numbers listed at n Urgent/Emergent requests must be discussed by direct consultation with Administrative Gender Male Female a radiologist Non-binary/Prefer not to disclose (X) Unknown 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 Provider Fax Contact Number for Critical Test Results Provider ID Department ID.
2 Provider Address/Location City postal Code Locum No Yes Primary Provider Name and Provider ID _____. Signature Date (dd-Mon-yyyy) Copy to Provider (last, first,middle) Copy to Fax Requested Procedure Reason for Exam Clinical question to be answered Relevant Previous Imaging Studies (Mandatory). Location Type Date (dd-Mon-yyyy) Attached copy o No o Yes Follow Up Stat report requested Patient follow up o n/a o No o Yes (phone/pager): o In ER o With GP o Other (specify): Current Patient Condition Weight o kg o lbs Height o cm o in Condition No Yes If Yes: Patient Pregnant n/a Date of LMP: Contraceptive Use Specify: Isolation Precautions Specify: Allergies Specify: Medications Specify: Mechanical lift/ transfer required Specify: Research Study Study Name: Study #: Obstetrical History (if applicable).
3 Describe: G T P. L A. LMP (dd-Mon-yyyy). Department Use Only Date format: dd-Mon-yyyy Time format: hh:mm Appointment Priority o 24 hr o 1 week o Next Avail. o Other (specify): Date Received Time Received Date of Appointment Time of Appointment 09922(Rev2021-12).
