MEDICAL IMAGING REQUISITION - VCH

1 MEDICAL IMAGING REQUISITIONhX-RayhCThUltrasoundhEchohAng iogram/InterventionalhNuclear MedicineAny Site h or Specify Site: _____ Appointment Date: _____ Time: _____EXAM(s) REQUESTED:PriorityhRoutinehUrgent Physician should consult with Radiologist for Urgent and Stat caseshStatPATIENTINFORMATIONPHN_____ ICBC _____WCB _____ Other _____Name: _____Address: _____Tel: _____ Other: _____Date of Birth:_____ _____ _____ M h F hPrevious Images? Location: _____PLACE MEDICAL IMAGING LABEL HEREE scort Requiredh Nurseh Por terh Volunteer Mode of transporth Wheelchairh Stretcherh Bed Otherh O2h Isolationh Portableh IV PumpDOCTORSTOCOMPLETETHISSECTION DEPARTMENT USEAble to give consent?

2 HYes hNo If the patient does not speak English, an interpreter MUST accompany the patientCopies of report to:This section MUSTbe completed if requesting CT Is Kidney Function abnormal?hYe s hNoHas patient had L-spine surgery?hYe s hNoIf YES for any of the above ORif requesting a CT Abdomen/Pelvis ORAngiogram: a current (within 3 months) eGFR and Creatinine are mandatory:eGFR: _____ Date: _____Creatinine: _____ Date: _____This section MUSTbe completed for all Core Biopsies, Angiograms and Interventional ProceduresINR: _____Date: _____ * Does the patient take anticoagulant/anti-platelet medication?hYes hNoPLATELETS: _____Date: _____ If yes please list medications:eGFR: _____Date: _____Creatinine: _____Date: _____*Patients may have to stop taking anticoagulant or anti-platelet medication prior to their appointment.

3 If this is unsafe for your patient pleaseconsult a : _____Date: _____No. of Images: _____Fluoro Time/Dose: _____/ _____Shielding used: _____Technologist comments on reversePERTINENT HISTORY / MEDICATIONS:Physician s signatureTel:Physician s MSP billing #:00083312, diabetichYes hNoOn metforminhYes hNoBreast FeedinghYes hNoPregnanthYes hNoLMP _____G _____ P _____ A _____Height _____ Weight _____ Previous contrast reaction?DD MON YYYYA ddressPO Box 200, McKay Street, Bella Coola, V0T 1C0231 East 15th Street, North Vancouver, V7L 2L7X-RayCTNuclear Medicine / Bone DensityUltrasound / EchocardiographyMammography (Screening)1403 Portage Road, Pemberton, V0N 2L05000 Joyce Avenue, Powell River BC, V8A 5R37000 Westminster Highway, Richmond, V6X 1A2X-Ray/ CT/ Nuclear Medicine / UltrasoundMammography (Diagnostic)

4 88 Waglisa Street, Bella Bella, V0T 1Z038140 Behrner, Squamish, V0N 3G05544 Sunshine Coast Highway, Sechelt, V0N 3A0CT2211 Wesbrook Mall, Vancouver, V6T 2B5CT/X-Ray/Fluoroscopy/Angio/Ultrasound Nuclear Medicine 899 West 12th Avenue, Vancouver, V5Z 1M9 Angiography / CT GI / GU / LithotripsyGordon and Leslie Diamond Health Care Centre Nuclear Medicine / Bone DensityUltrasoundX-Ray4380 Lorimer Road, Whistler, V0N 1B5 Telephone250-799-5311 ext 209604-984-5775604-984-5776604-984-57806 04-984-5721604-903-3860604-894-6939 ext 227604-485-3282604-244-5104604-278-9711 ext 4243250-957-2314 ext 234604-892-6025604-885-8608604-885-86226 04-822-7080604-822-7267604-875-4366604-8 75-4770604-875-4074604-875-4611604-875-4 340604-875-4287604-932-4911 ext #2228 Fax250-799-5350604-984-5777604-984-58856 04-984-5781604-984-5716604-903-3870604-8 94-6918604-485-3254604-244-5232604-244-5 232250-957-2702604-892-6072604-885-86526 04-885-8612604-822-9701604-875-5009604-8 75-5453604-875-4228604-875-4071604-875-5 009604-875-4228604-875-5831604-935-5326 Incomplete REQUISITION Forms Will Be

5 ReturnedImportant Patient Information Plan to arrive 15 minutes early to give yourself adequate time for parking. An interpreter must accompany patients who do not speak fluent English or the exam may be cancelled. Children and other third parties are not permitted in the examination rooms. Please ensure that children under the ageof 12 have someone to look after them during your exam or we will not be able to do your exam. Hospital staff cannotlook after your children. A $50 cancellation fee may apply to cancellations with less than 24 hours notice **Please bring your Care Card, WCB or ICBC information and Photo ID**..Department Use