Requisition for Medical Imaging
U/S
CT
MRI
Please complete in ink and fax copy of report to WorkSafeBC.
Claims Call Centre
Phone 604.231.8888
Toll-free 1.888.967.5377
M–F, 8:00 am to 4:30 pm
Date request submitted
Fax
604.233.9777
Toll-free 1.888.922.8807
Mail
WorkSafeBC
PO Box 4700 Stn Terminal
Vancouver BC V6B 1J1
(yyyy-mm-dd)
Worker information
Worker last name
First name
Middle initial
Gender
M
WorkSafeBC claim number
Address
Personal health number
Phone numbers
(CareCard)
(include area codes)
Home
Date of birth
(yyyy-mm-dd)
Work
Translator required?
Yes
F
Cell
Date of injury
(yyyy-mm-dd)
No
Examination required
Relevant prior imaging
Location of prior imaging
Date(s) of prior imaging
Is patient taking anticoagulants?
Patient’s weight
(yyyy-mm-dd)
Diagnosis/medical history
Essential medical information
Is patient pregnant?
Yes
No
Allergies, asthma, hay fever?
Yes
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(kg)
No
If yes, please specify
No
Normal renal function?
Yes
Yes
If no, recent eGFR/Creatinine
No
Wo r k e r s ’ C o mp e ns a t i o n B o a r d o f B. C .
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Requisition for Medical Imaging (continued)
Worker last name
First name
Is patient claustrophobic?
If yes, please prescribe medication and/or indicate open MRI
Yes
Middle initial
WorkSafeBC claim number
No
MRI only
History of welding, grinding, metal work, or a metallic foreign body in eye?
Yes
No
History of surgically implanted devices?
If yes, please provide orbital X-ray
report before MRI examination.
If yes, provide details/operative report
(e.g., vascular filter, stent, clip, cardiac pacemaker, defibrillator,
piercings, shrapnel, neurostimulator, ortho, or cochlear implant)
Yes
No
Ordering physician
Name
Phone number
Ordering physician signature
(include area code)
Fax number
(include area code)
MSP number
Copies of report to
(1)
WorkSafeBC
604.233.9777 or toll-free 1.888.922.8807
(2)
Fax number
(include area code)
(3)
Fax number
(include area code)
Personal information on this form is collected for the purposes of administering a worker’s compensation claim by WorkSafeBC in accordance with the Workers
Compensation Act and the Freedom of Information and Protection of Privacy Act. For further information about the collection of personal information, please contact
WorkSafeBC’s Freedom of Information Coordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or telephone 604.279.8171.
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