ultrasound - hours of operation general...
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Breast Ultrasound
Patient’s Last Name First Name Phone # Sex M F
NO APPOINTMENT NEEDED FOR X-RAYS
Referring Physician:
M.D.
REQUEST FOR STAT CASE :
VERBAL - TEL:
FAX:
CC:
CLINICAL INFORMATION
Left Right
ULTRASOUND - (Appointment Recommended But Not Always Needed)
X-RAY – (No appointment Required)
491 Lawrence Ave, WestLower level TwoToronto, ON M5M 1C7Tel : 416-781-9375Fax : 416-781-7175Email : info@cdimaging.caWeb : www.cdimaging.ca
HOURS OF OPERATION
Mon - Fri : 8 am - 5 pm Sat-Sun : 9 am - 2 pm
Tel : 416-781-9375Fax : 416-781-7175
Mammography
High Risk Routine Base Line
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CAR AccreditedOBSP Accredited
WOMEN’S IMAGING
PREGNANCY RELEASE FORM
I declare, to the best of my knowledge that I am not currently pregnant.
Patient’s Signature
FULLY DIGITALIZED FACILITY
Before ordering X-Rays, make sure female patients are not pregnant.Note : This requisition form can be taken to any licensed facility providing healthcare services including hospital and IHFs, such as those listed on the IHF Program website:http://www.health.gov.on.ca/en/public/programs/ihf/facilities.aspx.
BONE MINERAL DENSITOMETRY
3 Year follow- up
(By Appointment )
__________________________________________Date and location of previous scan
GENERALAbdomenFemale PelvisTransvaginalMale PelvisTransrectal/ProstateKidneys and BladderFollicle MonitoringOthers ___________
SMALL PARTSThyroidParotidSubmandibularNeckTesticular/ScrotalGroin/InguinalSoft Tissue/LumpOthers ____________
OBSTETRICAL
Same DayAppointment forUrgent Ultrasound
1ST Trimester IPS/NT2nd/3rd Trimester/Hight RiskAnatomy Scan (18-20 wks)BPP/EFC
Placenta EvaluationR/O Ectopic3D/4D Ultrasound of baby (Not covered by Ohip)
DLNMP ___________
UrgentNon-Urgent
MandibleTM JointsAdenoidsSoft Tissue NeckOrbits (FB)
ABDOMENKUBAcute (2 Views)
SKELETAL SURVEYArthritic Metastatic
UPPER EXTREMITIESShoulderClavicleAC JointsScapulaHumerusElbowForearmWristHandDigits
LOWER EXTREMITIES HipFemurKneeTibia & Fibula AnkleFootCalcaneusToes
CHESTChest PA & LAT Sternum Sternoclavicular Joints Ribs Chest PA (Immigration)
SPINE & PELVIS Cervical Spine Thoracic Spine Lumbo - Sacral Sacrum & Coccyx Pelvis Pelvis & HipsSI Joints
HEAD & NECKSkullSinusesFacial BonesNasal Bone
Health Card No: Version Code: Date of Birth :
MUSCULOSKELETAL L□□R Shoulder L□□R Elbow LO DR Wrist L□□R Hand L□□R Hip L□□R Knee L□□R Ankle/Foot L□□R Arm L□□R Forearm L□□R Thigh L□□R Hamstrings L□□R Calf L□□R Achilles Tendon L□□R Plantar Fascia L□□R Others
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Routine OBSP
Breast Implants Breast Implants RightLeft
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