CT/MRI REQUEST FOR EXAMINATION
Tel: 905-565-5914 Fax: 905-565-0789
r Ajax
r CT
r Mississauga
r MRI
Please Indicate area to be examined:
Patient Information
Referring Physician Information - Must include signature
First Name
Last Name
Name
Address
Home Phone
Other Phone
Phone
Fax
M
Health Card Number
|F
MM / DD
Sex
/ YYYY
Date of Birth
THIRD PARTY INFORMATION
Is this a WSIB Examination? Yes
MM / DD
r
MM / DD
/ YYYY
Date
PHYSICIANS SIGNATURE
Tel: 905-565-0433 Fax: 905-565-8836
No
WSIB Claim #
r
/ YYYY
Date of Accident:
Company Name
Contract#
Phone#
Fax#
Significant Clinical History/ Clinical Diagnosis:
FOR PATIENTS OVER 60 YEARS OF AGE
Most recent creatinine level within 3 months:
PT taking Metformin or Glucophage:
Previous contrast reaction:
#
Previous Relevant Exams:
Date:
r Yes
r Yes
MM / DD
r No
r No
Please list any allergies:
MRI PATIENT SCREENING (Must be completed with patient)
NONE
MRI
CT
X-ray
Ultrasound
Angiogram
Nuclear Medicine
Yes/No
rr
rr
rr
rr
rr
rr
rr
rr
rr
rr
rr
rr
rr
rr
rr
rr
rr
/ YYYY
Ever worked with metal (grinding, welding, etc.)
Previous eye injury with metal (Please provide orbit x-ray)
Pacemaker
Cochlear or Ear implants
Eye surgery or implants
Cerebral Aneurysm clips
Heart valve replacement
Intravascular coils, filters, stents
Joint replacement/prothesis, artificial limbs, pins, screws, plates
Surgical clips, staples
Neurostimulators, implanted mechanical devices, pumps, ports
Shrapnel, bullets, other metal
Hearing Aid
Piercing, tattoos, permanent make-up
Pregnant
Internal birth control device
Claustrophobia (if sedation required, to be provided by physician)
-Appropriate transportation to be arranged by patient.
Arthrography
When
Where
r
r
r
r
r
r
r
r
Please fax all previous reports with requisition.
Please list ALL SURGERY (specify date and type):
Patient Signature:
Date
MM / DD
/ YYYY
Technologist
Imaging Protocol (Radiologist Use)
If YES to any, please SPECIFY (date, type, implant model)
www.cmlhealthcare.com
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401 West
Exit Hwy 403 (QEW/Hamilton)
Exit Hwy 10/Hurontaio Street
Go North on Hurontario Street
Turn left on Kingsbridge Garden Circle
Turn left on Tucana Crt.,
Turn left into driveway
The MRI/CT Clinic is located on the
left hand side of Hurontario Street
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Cityside
Shopping
Centre
From Toronto:
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CT/MRI MISSISSAUGA
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The Emerald Centre
10 Kingsbridge Garden Circle
Mississauga, Ontario
L5R 3K6
905-568-3768
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FREE PARKING
CT/MRI AJAX
401
From Toronto:
401 East
Exit Westney Road South
Turn left (East) on Bayly Avenue
Turn left (North) on Harwood Avenue
Turn left into Harwood Plaza
(Located beside Tim Hortons)
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Hea
401
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PLEASE BRING OHIP CARD TO APPOINTMENT
Appointment Date:
Exete
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Harwood Plaza (South of 401)
300 Harwood Avenue South
Ajax, Ontario
L1S 2J1
905-426-8976
FREE PARKING
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