REQUEST FOR MRI
❑ OP ❑
Grand River Regional MRI Unit
Fax Requisitions to (519) 749-4296
Located at Grand River Hospital
835 King Street West Kitchener, ON N2G 1G3
Referring Physician:
IP–Hospital_________Unit______
ALL INFORMATION PROVIDED IS FOR THE CARE OF THE PATIENT
Name (Last, first):
Address:
Address:
Tel #:
Fax #
Region / Organ of Interest
DOB (Y/M/D)
❑M
HC#:
Weight
❑F
Height
WSIB Claim #:
*Pt. Consented Contact # :
**Can message be left at this #?
❑ YES
❑ NO
Clinical History
Check: Cardiovascular Disease  Yes  No Age > 70  Yes  No Diabetic  Yes  No
Renal Disease  Yes  No Metformin  Yes  No If yes to 1 or more provide a recent (3 month), creatinine
level: _______ , eGFR______ Date drawn: _______________
Critical Booking Information – Incomplete information will result in request being returned – NO BOOKING.
 If the patient has a cardiac pacemaker, Brain Aneurysm clip, cochlear implant or neurostimulator the MRI
will not be performed.
Check Relevant Prior Studies.
 All non Grand River Hospital reports must be submitted with requisition.
 All non Grand River Hospital studies/films must accompany patient on day of appointment.
❑ MRI
❑ CT
❑ ULTRASOUND
❑ MAMMOGRAPHY
❑ ANGIO
❑ NUC MED
❑ X-RAY
❑ OTHER
Check ALL Surgeries – MRI will be performed no sooner that 6 – 8 weeks post surgery.
❑ HEAD/EAR
❑ NECK
❑ SPINE
❑ CHEST
❑ ABDOMEN
❑ EXTREMITIES
❑ OTHER
Please answer the following questions carefully.
Has the Patient EVER worked with metal (grinding or welding)?
❑ Yes
❑ No
Has the Patient EVER had metallic foreign body in their eye?
❑ Yes
❑ No
If the answer is yes to BOTH questions above – submit orbit report with requisition.
Is there a chance the patient is pregnant?
❑ Yes
❑ No
Does the patient require assistance transferring?
❑ Yes
❑ No
Is the patient claustrophobic?
❑ Yes
❑ No
________________________________________ ___________________________
Physician Signature
Date of Signature
SECTION BELOW FOR MRI USE ONLY
Protocol/Priority
H/M/L
Appointment Date & Time
*Patient has consented to using this number for contact and **leaving messages.
WS 3151 (2009/06)