U3T

MRI REQUISITION

4401 University Drive, Lethbridge AB T1K 3M4
Toll Free: 1-844-425-5267
Fax: 403-328-1218 www.u3t.ca

Office use only:

Exam code:

Name:
Address: Postal Code:
City: Province:
Phone #:
AHC #: WCB#
Patient pay Affiliate
Age: DOB:
Male Female
Referring physician:
Clinic name:
Fax reports to #:
Send 2nd copy to:
Clinic name:
Fax reports to #:

HISTORY AND PROVISIONAL DIAGNOSIS:

Please provide relevant prior imaging and/or reports with requisition
Claustrophobic? Yes No If yes, prescribe anxiolytic.
Pregnant? Yes No LMP:
Breastfeeding? Yes No
Does the patient have a cardiac valve, stent, cerebral aneurysm clip/coil, or any other
implanted surgical device?
Yes No
If yes, please provide details:
Does the patient have a history that could result in a metallic foreign body in their eye
(e.g., working with metal)?
Yes No If yes, was it removed by a physician? Yes No
If yes, was an orbital x-ray performed?
Yes No
If yes, location where performed:
Renal Function: Normal Abnormal
If abnormal, GFR= Creatinine= Draw date:

 

PATIENTS WITH THE FOLLOWING CONDITIONS CANNOT RECEIVE AN MRI AT U3T:

Cardiac Pacemaker Defibrillator Cochlear Implant Neurostimulator

Patients aged 8-17 will only receive an MRI if ordered by a physician licensed in Canada. U3T does not scan patients under the age of 8.

HEAD:

Carotid & Circle of Willis MRA
Head:
        Routine
        MS
        MS Screen (Head & Cervical Cord)
        Seizure
        Trauma
Internal Auditory Canal (IAC)
Orbits
Paranasal sinuses
Pituitary/Selia
TMJ

BODY:

Abdomen
Abdomen & Pelvis
MR Enterography (Small Bowel)
Brachial Plexus
Chest Wall
Extremity masses
MRCP
MRA Renal or Aorta
Neck
Pelvis
Piriformis
Prostate

JOINTS: Left Right

Ankle
Elbow
Foot
Hand
Hip
Knee
Shoulder
Wrist
MR Arthrogram
(Check joint also)

SPINE:

Cervical
Thoracic
Lumbar
L-spine Spondylolysis Screen
Sacroiliac Joints

CANCER & ANEURSYM SCREEN:

Brain, neck, abdomen & pelvis cancer screen, plus brain & aortic aneurysm screen (read more)

OTHER:

PREPARATION FOR MRI PROCEDURES:

  • Take medications as necessary.
  • Do not eat or drink for 4 hours before all abdominal studies – you may, however, take prescribed medications with a few sips of water.
  • Exams typically take 30 minutes.
  • Please discuss any allergies or medication requirements at time of booking.
  • Please inform the technologist if there is a possibility of pregnancy.
  • Unless otherwise specified, please arrive at least 30 minutes prior to your scheduled examination time. If you are late for your appointment, you may need to be rescheduled.
  • We require 24 hours notice to cancel or reschedule your appointment. “No shows” are subject to a $100 administration fee.
  • Be prepared to provide your license plate number upon check-in for parking validation.
  • Patients will be asked to change into provided garments for their scan. Please do not wear or bring jewelry or valuables to your appointment. U3T cannot be responsible for lost or stolen valuables.
  • Please note that children requiring supervision CANNOT be brought to your appointment.
  • Please inform us of any limited mobility prior to your examination – wheelchair assistance is available upon request.
  • We accept Debit, Visa, Mastercard and Cash ONLY – we do not accept personal cheques.
map

 

 

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