CT/MRI MISSISSAUGA REQUEST FOR EXAMINATION Tel: 905-565-5914 Fax: 905-568-0941 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: 905-426-3741 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 IMG-CTMRI-01 Tr ud ren Sor Mississauga Marketplace Eg lin to nA ve . W . El la Av e. r. to D Hu e ro Cir cl rw in dD Gar de n Fa i nt ar io 403 St ridg e r. . King sb 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 ea Cityside Shopping Centre From Toronto: • • • • • • • • uA ve . CT/MRI MISSISSAUGA s King The Emerald Centre 10 Kingsbridge Garden Circle Mississauga, Ontario L5R 3K6 905-568-3768 e dg bri Ga rde n Circle urn t hb Ra 403 Rd . .W 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) y Parr Exete W Rd. d ho oo u se C re s. ood r Rd. Harw S. Ave. d. iral R Adm er R d . St. Exet Hunt 22 . ie Kenz t. E yly S Ba Ave. Mac arch Mon Harwood Place Ave. 22 PLEASE BRING OHIP CARD TO APPOINTMENT Appointment Date: . Cres d. iral R s King Adm . d Rd woo 401 Harwood Plaza (South of 401) 300 Harwood Avenue South Ajax, Ontario L1S 2J1 905-426-8976 FREE PARKING ther Hea • • • • • d. iral R Adm Time: Bayly . St. E