YOU MUST BRING THIS REQUISITION, HEALTH CARD, OR WSIB CLAIM
NUMBER TO YOUR APPOINTMENT OR YOU MAY BE RESCHEDULED
FAX:
519 749-4296
835 King Street West, Kitchener N2G 1G3
PHONE: 749-4262
DEPARTMENT OF MEDICAL IMAGING
OUTPATIENT REQUISITION
Please complete ALL sections
Incomplete requisitions will be returned
ALL INFORMATION PROVIDED IS FOR THE CARE OF THE PATIENT
Referring Physician Name:
Patient Name (Last, first)
Phone #:
FAX # :
DOB (Y/M/D)
M
F
Does patient need assistance (i.e. transferring) Yes  No 
PHYSICIAN SIGNATURE
HC# :
Date of signature
Pt. Consented Contact Phone # :
RELEVANT CLINICAL
WSIB Claim #:
Consented for message to be left at this #
Yes  No 
Appointment Date/Time
HISTORY This area MUST be completed or requisition will be returned.
(For office use)
Complete for CT & Interventional (Exception CT Spines & Therapeutic Injections)
Cardiovascular Disease Yes  No  Stroke/TIA Yes  No  Age > 70 Yes  No  Diabetic Yes  No 
Kidney Disease/Solitary Kidney Yes  No  Current/Previous Chemotherapy (oral/IV) Yes  No 
Does the pt. have other medical conditions or take any meds that may predispose to nephrotoxicity? Yes  No 
If yes to 1 or more, a creatinine level drawn within the past 3 months must be provided.
Creatinine level: ____________, Date drawn:__________________ eGFR:__________
Interventional/Angio (including CT or US guided procedure.)
General Radiography
Blood Thinners Yes  No 
Bone Mineral Densitometry
Type_____________________ Dose _________________
ULTRASOUND
Upper Abdomen
Gallbladder
Aorta
Kidneys
Liver
Abdomen
complete
Pelvis
Gynecological
Male Pelvis
Prostatetransrectal
Appendix
Kidneys &
Bladder
Obstetric
Routine
preg
Highrisk preg
BPP
Msk
Shoulder
Knee
Ankle
Hand/Wrist
Elbow
 Right
 Left
Other Exams or Procedures ______________________________
Doppler
Pediatric
Carotid
Head
Segmental Pressures Sacrum
(arterial doppler)
Hips
Upper  Lower TOS Pylorus
DVT (venous)
 Upper  Lower
 Right  Left
Doppler Hepatic/Portal Vein
Other
Neck
Thyroid
Scrotum
Allergy to IV Contrast Yes  No 
CT Angio, be specific ________________________________
Head-routine Sinuses
Chest Routine
Orbits
Neck
 Chest High Resolution  Extremity, be specific _______________________________
Facial bones
Temporal Abdomen
 Spine, Must specify levels____________________________
bones
Pelvis
CT
 Other Exams or Procedures ___________________________________________________________________________
GRH2541 (REV.05/15)
YOU MUST BRING THIS REQUISITION, HEALTH CARD, OR WSIB CLAIM
NUMBER TO YOUR APPOINTMENT OR YOU MAY BE RESCHEDULED
835 King Street West, Kitchener N2G 1G3
PHONE: 749-4262
FAX: 749-4296
DEPARTMENT OF MEDICAL IMAGING
OUTPATIENT REQUISITION
Please complete ALL sections
Incomplete requisitions will be returned
All patients require a scheduled appointment time for all examinations except general x-rays (i.e. Chest,
Knee, Spine etc.), which may be done Monday – Friday 9:00 AM – 4:00 PM.
Please allow yourself extra time to park.
All diabetic patients must consult with their doctor before following preparation instructions.
PATIENT PREPARATION INSTRUCTIONS
 GI Series (Esophagus, stomach, duodenum or small bowel)
 Nothing by mouth after midnight prior to examination. (Except to swallow necessary medication)
 Colon (Barium Enema)
 Clear fluids only the day before the examination.
 Medications may be taken with a small amount of water.
 Nothing to eat or drink after midnight. Bowel cleansing agent as recommended by your doctor.
 Interventional/Angio Procedures
 Nothing to eat or drink 4 hours prior to examination. (Except to swallow necessary medication)
 Bring all current medications with you
 Bone Densitometry
 NO barium x-rays or Nuclear Medicine scans one week prior to exam. Avoid clothing with metal
fasteners.
 NO calcium pills on day of exam.
 All CT Exams
 No solid food 4 hours prior to examination. Fluids may be taken up to time of examination.
 Pediatric patients receiving sedation: Nothing by mouth for 4 hours prior to the examination.
 Pediatric patients not receiving sedation: Nothing by mouth for 2 hours prior to the examination.
Ultrasound
Abdomen (includes liver, gallbladder, pancreas, kidneys, aorta, spleen)
 Nothing to eat or drink after midnight. Medications may be taken with a small amount of water.
Kidneys only No prep
Abdomen and Pelvis
 Nothing to eat or drink after midnight, but finish drinking 1 litre (32 oz) of water one hour before
appointment. Bladder must be full.
Pelvis/Pregnancy/Appendix/Kidneys&Bladder
 Finish drinking 1 litre (32 oz) one hour before appointment. Bladder must be full.
Transrectal Prostate
 Fleet enema one hour prior to exam.
 Please forward any relevant information i.e., X-Ray films, CT Scans, MRI’s, Ultrasounds,
BMD and Nuclear Medicine.
 Some tests require a consent to be signed. If unable to sign consent, (pediatric, language
barriers etc.) next of kin or legal guardian must accompany the patient.