REQUEST FOR EXAMINATION
r STAT
Patient Information
Physician Information
First Name
Last Name
Name
Address
Home Phone
Other Phone
Phone
Fax
M
OHIP
Version Code
|F
MM / DD
Sex
Date of Birth
Appointment Date/Time
MM / DD
/ YYYY
/ YYYY
Date
Doctor’s Signature
Copy To
/ YYYY
Appointment Date
Appointment Time
Name
X-Ray (No Appointment)
SPINE & PELVIC
UPPER EXTREMITIES
r Single/KUB
r Acute (includes PA chest)
r Cervical Spine
r Thoracic Spine
r Lumbar (L/S) Spine*
r L/S Spine Pelvis &
R L
HEAD & NECK
r Neck for soft tissues
r Skull
r Sinuses
r Facial Bones
r Nose
r Mandible
r Orbits
r Temporomandibular joint -TMJ
CHEST
r Chest PA & LAT
r Ribs: r R r L r B
(includes PA chest)
r Sterno – Clavicular Jts.
r Sternum
Fax #
Ultrasound (By Appointment)
ABDOMEN
MM / DD
S.I. Joints*
r Sacrum/Coccyx
r S. I. Joints
r Pelvis
LOWER EXTREMITIES
R L
r r Hip
r r Femur
r r Knee
r r Tib. & Fib.
r r Ankle
r r Foot
r r Heel
r r Toe: 1 2 3
r r Elbow
r r Forearm
r r Shoulder
r r Humerus
r r Clavicle
r r A. C. Joints
r r Scapula
r r Wrist
r r Scaphoid
r r Hand
r r Finger: 1 2
2 3 4
1
4 5
5
3 4 5
r Abdomen
r Abdomen & Pelvis
r Pelvis - Transvaginal unless contraindicated
r PVR -Post Void Residual r Bladder
r Transrectal Prostate
r Renal
r Abdominal Wall
r Nuchal Translucency- IPS (11-13 weeks)
r OB — Under 16 weeks
MM / DD / YYYY
LMP:
r OB — Over 16 weeks
r Thyroid and/or Neck
r Aorta
r Carotid
r Scrotum
r Inguinal canal:
r Right r Left
r Upper Extremity Venous: r Right r Left
r Upper Extremity Arterial: r Right r Left
r Lower Extremity Venous: r Right r Left
r Lower Extremity Arterial: r Right r Left
r MSK
r Other
r Other:
r Echocardiogram:
Clinical History Requested
BMD r WSIB
Gastrics (By Appointment)
r Baseline
r 3yr- First follow-up
Low Risk:
High Risk:
r 5 year
r 1 year
r
r
r
r
r
UGI
Barium Swallow
Small Bowel
UGI/SBFT
Barium Enema
Breast Imaging (By Appointment)
r Mammogram
r Ultrasound
r Left
r Right
r Bilateral
r Implants
r OBSP
Right
Left
www.cmlhealthcare.com
24-hour notice required to cancel appointment or $75 charge will be billed to patient.
* As per Ministry of Health Guidelines
IMG-ON-GTA-04
* Please bring your health card and this paper with you to your appointment.
(X) X-Ray
(U) Ultrasound
(M) Mammography
Brampton
North York
164 Queen Street E.
Phone: 905-450-6717
Fax: 905-450-6719
(X/U/M/B/V)
1 hour Validated Prkng
4949 Bathurst St.,Unit #100
Phone: 416-223-5460
Fax: 416-223-8335
(X/U/M)
Bathurst & Finch
Free Parking
Mississauga
10 Kingsbridge Garden, #100
Phone: 905-568-3768
Fax: 905-568-9652
(U/CT/MRI)
Free Parking
Hurontario & 403
71 King Street W., Unit #102
Phone: 905-897-1144
Fax: 905-897-1146
(X/U/B/M/V)
Oakville
1525 Cornwall Rd. , Suite 18
Phone: 905-815-0999
Fax: 905-815-0997
(V)
581 Argus Rd. , Lower Level
Phone: 905-338-6644
Fax: 905-338-6656
(X/U/B-Lab Services)
4800 Leslie Street, Unit #LL
Phone: 416-493-1011
Fax: 416-493-1019
(X/U/M/B/F/E/V)
Leslie & Sheppard
Free Parking
4430 Bathurst St., Unit #206
Phone: 416-226-6941
Fax: 416-226-4270
(X/U/B/V - Lab)
Free Parking
5801 Yonge Street, Unit #5
Phone: 416-222-6989
Fax: 416-222-4278
(X/U/M/B/V)
Free Parking
Food Basics plaza
491 Lawrence Ave. W., Bsmnt
Phone: 416-781-9375
Fax: 416-781-7175
(X/U/M/B)
Bathurst & Lawrence
5 Fairview Mall Dr., Unit #100
Phone: 416-499-3559
Fax: 416-499-4631
(X/U/M/B/E/V)
Close to Fairview Mall
(D) Doppler
(F) Fluoroscopy
1017 Wilson Ave., Unit #100
Phone: 416-631-7581
Fax: 416-631-9759
(X/U - Lab Services)
Downtown
Toronto
1881 Yonge St., Unit #402
Phone: 416-966-3886
Fax: 416-487-8746
(V)
Yonge & Davisville
1881 Yonge St., Unit #612
Phone: 416-487-2425
Fax: 416-487-0746
(U)
Yonge & Davisville
11 King Street W., Suite C-100
Phone: 416-864-1814
Fax: 416-864-1499
(X/U/F)
Yonge & King
790 Bay St., Unit #418
Phone: 416-260-9382
Fax: 416-260-2274
(X/U)
Corner of Bay & College
Women’s Imaging Centre
790 Bay St., Unit # 520
Phone: 416-260-1974
Fax: 416-260-1687
(U)
Corner of Bay & College
(B) Bone Mineral Density
280 Spadina Ave., Unit #306
Phone: 416-603-1197
Fax: 416-603-1199
(X/U/M/B/F)
At Spadina & Dundas
In Dragon City Mall
39 Pleasant Blvd., 2nd Flr
Phone: 416-928-3467
Fax: 416-928-3502
(U/B/N)
One block south of St Clair
East off of Yonge
586 Eglinton Ave.E., #104
Phone: 416-485-9471
Fax: 416-485-9309
(U/X/M/B)
Eglinton, one block west
of Bayview
Thornhill
7131 Bathurst St., #LL03
Phone: 905-889-2400
Fax: 905-889-2455
(X/U/B - Lab Services)
Bathurst & Steeles
Free Parking
Newmarket
17215 Leslie St
Phone: 905-836-2626
Fax: 905-836-5043
(X/U/M - Lab Services)
No Frills Plaza
Free Parking
For additional locations across Ontario, visit www.cmlhealthcare.com
Preparation & Instructions
(G) Gastric
Ultrasound Preparation and Instructions
No eating or drinking (smoking or chewing gum) 8 hours prior to appointment.
Obstetrical/Pelvis
(V) Vascular
(N) Nuclear
Scarborough
Ajax
1371 Neilson Rd., Unit #309
Phone: 416-287-1818
Fax: 416-287-2126
(X/U/B)
White Medical Bldg.
300 Harwood Ave. S.
Phone: 905-426-8976
Fax: 905-426-7843
(CT/MRI)
Free Parking
4190 Finch Ave. E., #LL04
Phone: 416-293-5940
Fax: 416-293-6036
(X/U/M/B/E - Lab )
Finch & Midland
Free Parking
2901 Lawrence Ave. E.,
Unit #103
Phone: 416-266-7535
Fax: 416-266-9631
(X/U/B - Lab Services)
4 story tan medical
building
Pickering
1105 Kingston Road, #D202
Phone: 905-420-3068
Fax: 905-420-6057
(X/U/M/B - Lab-Services )
Above Shoppers
Free Parking
Markham
10 Unionville Gate, Unit #204
Phone: 905-479-3945
Fax: 905-479-5538
(X/U/M/B)
Unionville Med Centre
Free Parking
6633 Hwy 7, Unit #5
Phone: 905-294-4880
Fax: 905-472-6629
(X/U)
Free Parking
Connect with us
These instructions are IMPORTANT. Please follow them.
Abdomen
(E) Echo
@cmlhealthcare
* CML is a scent free environment
Gastric Preparation and Instructions
Stomach, UGI, Barium Swallow
Nothing to eat or drink after midnight, which includes chewing gum, candies and smoking.
34oz or 1Litre of water 1 hour prior to appointment. Do not go to the washroom.
Small Bowel Preparation (Allow 2-5 hours for appointment)
Abdomen/Pelvis
Nothing to eat or drink after midnight, which includes chewing gum, candies and smoking.
No eating or drinking 8 hours prior to appointment. 34oz or 1Litre of water
1 hour prior to appointment. Do not go to the washroom.
Colon Examination (Barium Enema)
Prostate (Transrectal)
Clear fluids for the two (2) days prior to this examination. (fruit juice, bouillon, clear beef or
Fleet enema 2 hours before the examination (kit may be purchased at your
pharmacy.) Drink 34oz or 1Litre of water 1 hour prior to appointment.
Do not go to the washroom.
Bone Mineral Densitometry
Do not take calcium supplements for 24 hours prior to examination.
Patients are asked to wear clothing without zippers or metal attachments.
Mammogram
Remove deodorant, powder and perfume prior to appointment.
chicken broth, consomme, gelatin, popsicles and coffee or tea with sugar.
Two days before the exam: Clear fluids
The day before the exam: Clear fluids
Take: 10 ozs. (chilled) Magnesium Citrate at 4:00 p.m., 3 Dulcolax tablets at 6:00 p.m.
(Do not crush or chew tablets), At least 5 large glasses of water during the afternoon and
evening prior to examination.
Day of the examination: May have clear fluids only until examination is completed.