MEDICAL IMAGING REQUISITION Tel. 416-756-6167 SEE BELOW FOR FAX NUMBERS PREFERRED SITE: q General q Branson Patient’s Name: HC#: Version: DOB: Sex: M F Tel#: Physician’s Billing Number: Physician’s Name Printed: Signature: Tel: q I understand that the Radiologist may require to schedule additional examinations related to the current investigation on my behalf. Initial here: Clinical Information/Indication for Test: nygh.on.ca Radiologists Dr. E. LaMere, Chief Dr. P. Causer Dr. L. Grinblat Dr. B. O’Hayon Dr. K. Mak, Branson Site Director Dr. K. Cranstoun Dr. N. Isaac Dr. D. Pham Dr. S. Armstrong Dr. H. Deif Dr. I. Jacobs Dr. H.R. Stoneman Dr. A. Bass Dr. L. Friedman Dr. E. Lai Dr. J. Wortsman Dr. M. Chang Dr. B. Ginzburg Dr. R. Margau Dr. T. Yates Dr. G. Chow Dr. R. Goldberg Dr. C. MacAdam BREAST IMAGING SERVICES AND BMD q Routine Screening (including OBSP/High Risk OBSP) q Diagnostic (Workup) q Breast Ultrasound q Right q Left q Other: Tel. 416-635-2550 Fax 416-635-2401 FLUOROSCOP Y Fax:416-756-6766 q Barium Swallow q Upper GI Series q Small Bowel Follow-thru q Barium Enema q Other: q Baseline q Low Risk q High Risk Date of last BMD: BONE DENSITY (BMD) X-RAY Chest & Abdomen: Spine: Head & Neck: q Chest (2 Views) q Cervical q Skull q Ribs R L q Thoracic q Sinuses q Sternum q Lumbo-Sacral q Facial Bones q SC Joints q Sacrum & Coccyx q Nasal Bones q Abdomen Single View q S-I Joints q Mandible q Abdomen (2 views) q Soft Tissue Neck Upper Extremities: Lower Extremities: Skeletal Survey: q Shoulder R L q Pelvis q Arthritic q Clavicle R L q Hip R L q Metastatic q Scapula R L q Femur R L q Scoliosis q AC Joints R L q Knee R L q Bone Age Study q Humerus R L q Ankle R L q Elbow R L q Tibia & Fibula R L q Forearm R L q Foot R L q Wrist R L q Calcaneus R L q Scaphoid R L q Toes R L No. 1 2 3 4 5 q Hand R L q Finger R L No. 1 2 3 4 5 q Other: ULTRASOUND Fax:416-756-6370 q Abdomen Complete q Female Pelvic (Transabdominal) q Transvaginal q Hysterosonogram Obstetrical Date LNMP q IPS NT Dating (12 - 14 WKS) q Anatomic (18 - 20 WKS) q Medical Indication Vascular Doppler q Carotid q Arterial Upper Extremity R L q Arterial Lower Extremity R L q Venous Upper Extremity R L q Venous Lower Extremity R L q Limited Abdomen (GB, Liver, Renal, etc.) q Male Pelvic q Transrectal Small Parts q Baby Brain q Neck/Face q Salivary Glands q Thyroid q Testicular q Other: MSK q Baby Hips R L q Knee R L q Shoulder R L q Other: See other side for site addresses, patient preparation instructions, contact info, for CT/Interventional, MRI, Cardio Resp and Pre-Operative Breast Localizations NUCLEAR MEDICINE Tel. 416-756-6258 Fax 416-756-5995 Bone Scan: q Whole Body q Specific Site q SPECT Gallium Scan: q Whole Body q Specific Site q SPECT Thyroid Scan: q Uptake & Scan q Scan q Uptake Liver: q RBC (Hemangioma) q Sulfur Colloid q Renal Scan q Captopril Renal Scan q Lasix Renal Scan (?Hypertension) (?UPJ Obstruction) q Brain Scan SPECT q Biliary Scan (HIDA) q Lung Scan (V/Q) q Meckels q Gastric Emptying Scan q Salivary Scan q Parathyroid Scan q I-131 Whole Body Scan q Other: IMPORTANT: Reports for relevant imaging studies performed outside North York General Hospital MUST accompany this requisition.

MEDICAL IMAGING REQUISITION Radiologists Tel. 416-756 …See other side for site addresses, patient preparation instructions, contact info, for CT/Interventional, MRI, Cardio Resp

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Page 1: MEDICAL IMAGING REQUISITION Radiologists Tel. 416-756 …See other side for site addresses, patient preparation instructions, contact info, for CT/Interventional, MRI, Cardio Resp

MEDICAL IMAGING REQUISITIONTel. 416-756-6167

SEE BELOW FOR FAX NUMBERSPREFERRED SITE: q General q Branson

Patient’s Name:

HC#: Version: DOB: Sex: M F

Tel#: Physician’s Billing Number:

Physician’s Name Printed: Signature: Tel:

q I understand that the Radiologist may require to schedule additional examinations related to the current investigation on my behalf. Initial here:

Clinical Information/Indication for Test:

nygh.on.ca

RadiologistsDr. E. LaMere, Chief Dr. P. Causer Dr. L. Grinblat Dr. B. O’HayonDr. K. Mak, Branson Site Director Dr. K. Cranstoun Dr. N. Isaac Dr. D. PhamDr. S. Armstrong Dr. H. Deif Dr. I. Jacobs Dr. H.R. StonemanDr. A. Bass Dr. L. Friedman Dr. E. Lai Dr. J. WortsmanDr. M. Chang Dr. B. Ginzburg Dr. R. Margau Dr. T. YatesDr. G. Chow Dr. R. Goldberg Dr. C. MacAdam

BREAST IMAGING SERVICES AND BMDq Routine Screening (including OBSP/High Risk OBSP)q Diagnostic (Workup)q Breast Ultrasound q Right q Leftq Other:

Tel. 416-635-2550 Fax 416-635-2401 FLUOROSCOPYFax:416-756-6766q Barium Swallowq Upper GI Seriesq Small Bowel Follow-thru

q Barium Enemaq Other:

q Baselineq Low Riskq High RiskDate of last BMD:

BONE DENSITY (BMD)

X-RAYChest & Abdomen: Spine: Head & Neck:q Chest (2 Views) q Cervical q Skullq Ribs R L q Thoracic q Sinusesq Sternum q Lumbo-Sacral q Facial Bonesq SC Joints q Sacrum & Coccyx q Nasal Bonesq Abdomen Single View q S-I Joints q Mandibleq Abdomen (2 views) q Soft Tissue Neck

Upper Extremities: Lower Extremities: Skeletal Survey:q Shoulder R L q Pelvis q Arthriticq Clavicle R L q Hip R L q Metastaticq Scapula R L q Femur R L q Scoliosisq AC Joints R L q Knee R L q Bone Age Studyq Humerus R L q Ankle R Lq Elbow R L q Tibia & Fibula R Lq Forearm R L q Foot R Lq Wrist R L q Calcaneus R Lq Scaphoid R L q Toes R L No. 1 2 3 4 5q Hand R L q Finger R L No. 1 2 3 4 5 q Other:

ULTRASOUND Fax:416-756-6370q Abdomen Completeq Female Pelvic (Transabdominal)q Transvaginalq HysterosonogramObstetrical Date LNMPq IPS NT Dating (12 - 14 WKS) q Anatomic (18 - 20 WKS)q Medical IndicationVascular Dopplerq Carotidq Arterial Upper Extremity R L q Arterial Lower Extremity R Lq Venous Upper Extremity R Lq Venous Lower Extremity R L

q Limited Abdomen (GB, Liver, Renal, etc.)q Male Pelvicq TransrectalSmall Partsq Baby Brain q Neck/Face q Salivary Glands q Thyroidq Testicular q Other:MSKq Baby Hips R Lq Knee R Lq Shoulder R Lq Other:

See other side for site addresses, patient preparation instructions, contact info, for CT/Interventional, MRI, Cardio Resp and Pre-Operative Breast Localizations

NUCLEAR MEDICINE Tel. 416-756-6258 Fax 416-756-5995Bone Scan: q Whole Body q Specific Site q SPECTGallium Scan: q Whole Body q Specific Site q SPECTThyroid Scan: q Uptake & Scan q Scan q UptakeLiver: q RBC (Hemangioma) q Sulfur Colloid

q Renal Scan q Captopril Renal Scan q Lasix Renal Scan(?Hypertension) (?UPJ Obstruction)

q Brain Scan SPECT q Biliary Scan (HIDA)q Lung Scan (V/Q) q Meckelsq Gastric Emptying Scan q Salivary Scanq Parathyroid Scan q I-131 Whole Body Scan q Other:

IMPORTANT: Reports for relevant imaging studies performed outside North York General Hospital MUST accompany this requisition.