Computed Tomography (CT) Request - Alberta Health Services

1 <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.

2 If no current results available, please indicate date ordered(yyyy-Mon-dd)Serum Creatinine (within 90 days)GFR Date (yyyy-Mon-dd)Specific anatomical area to be examinedRelevant clinical history/presumptive diagnosisClinical question to be answeredPatient label here or information below is requiredLast NameFirst NameBirthdate (yyyy-Mon-dd)GenderAddress (street, city, province, postal code)PHND aytime PhoneInpatient locationWCB Claim NumberConditionNoYesIf Yes: Pediatric/Special Needs ooRequires sedationoNo oYesIsolation PrecautionsooSpecify type:DiabeticooMetformin (Glucophage) oNo oYes (Patient may have to stopMetformin for 48 hours post contrast media injection)Asthma oon/aHistory of a Severe anaphylaxis reactionooCarries an EpipenoNo oYesAllergies (include any reaction to contrast media)ooSpecify:Organ TransplantooSpecify:Power Compatible Port/PICC/CVC insituooSpecify:Mechanical lift/Transfer requiredooSpecify:Research StudyooStudy Name: Study Number.

3 Date of LMP (yyyy-Mon-dd)Height ocm oinWeight oKg olbsComputed Tomography (CT) RequestReferring Physician(PRINT first and last name)Physician Phone(required)Physician Fax(required)Contact Number for CriticalTest Results (required)SignatureDate (yyyy-Mon-dd)Copy to Physician (first and last)Copy to Fax