RAI

DIAGNOSTIC IMAGING
REQUISITION

Booking Information

Phone: 403-328-1122
Fax: 403-328-1218

1122 Scenic Drive South
Lethbridge AB T1K 7E5

www.lethbridgeradiology.com

Appointment date / time:

BRING VALID HEALTH CARE CARD & THIS FORM. If you are unable to attend your appointment, please call to cancel or reschedule at least 2 hours prior to your appointment. NO SHOWS MAY BE CHARGED. CHILDREN ARE NOT ALLOWED IN EXAM ROOMS. CHILD CARE IS NOT PROVIDED

Name:
Address: Postal Code:
City: Province:
Phone #:
AHC #: OUT OF PROVINCE

WCB

PATIENT

PRIVATE

Age:

DOB:

LMP:

Male Female

PREGNANT YES NO

Referring physician:
Clinic name:
Fax reports to #:
Send 2nd copy to:
Clinic name:
Fax reports to #:

HISTORY & PROVISIONAL DIAGNOSIS:

Wheelchair, walker, limited mobility, etc. (allow more time)

Relevant prior imaging:


M.D.

MAMMOGRAPHY

IMPLANTS (requires more time)
PREVIOUS BREAST CANCER

On the day of the exam, wash off all deodorants, perfumes, powders and/or lotions under the arm and across the chest.

X-RAY (No preparation required)

BODY PART:

BONE DENSITOMETRY

Bring a list of all prescribed medications and amount of calcium and vitamin D in supplement form. No metal (including zippers and underwire bras) from the armpit down to just above the knees. If possible, remove bellybutton ring. No contrast exams (e.g., barium, CT, MRI, or nuclear imaging studies) for one week prior to BMD. Weight limit is 330 lb for this exam.

BODY COMPOSITION (a charge will apply, call for more information)

ULTRASOUND (PREPARATION REQUIRED)

ABDOMEN

After midnight, nothing to eat or drink, no chewing gum or candies and no smoking. For infants, withhold the last feeding prior to the appointment time. Medication(s) can be taken with a small amount of water.

PELVIS

FINISH drinking 4 glasses of water, 8 oz. each (1 L total), 90 minutes before the appointment time. DO NOT VOID. DO NOT SUBSTITUTE WITH ANY OTHER LIQUID. A full bladder is necessary to perform the exam. If the bladder is not full,the examination will be rescheduled. Children (12 and under) are only required to drink 2 glasses of water, 8 oz. each (500 mL total).

ABDOMEN AND PELVIS

After midnight, nothing to eat, no chewing gum or candies and no smoking. FINISH drinking 4 glasses of water, 8 oz. each (1 L total), 90 minutes before the appointment time. DO NOT VOID. DO NOT SUBSTITUTE WITH ANY OTHER LIQUID. A full bladder is necessary to perform the exam. If the bladder is not full, the examination will be rescheduled. Children (12 and under) are only required to drink 2 glasses of water, 8 oz. each (500 mL total).

OBSTETRIC

90 minutes prior to your appointment, empty your bladder, then drink water with 15 minutes as specified below. The amount of water you need to drink depends on how far along you are in your pregnancy:

  • Up to 25 weeks - 3 glasses of water, 8 oz. each (750 mL total)
  • Over 25 weeks - 1 glass of water, 8 oz. (250 mL total)

DO NOT VOID. DO NOT SUBSTITUTE WITH ANY OTHER LIQUID. A full bladder is necessary to perform the exam. If the bladder is not full, the examination will be rescheduled. DO NOT BRING CHILDREN TO YOUR APPOINTMENT, unless accompanied by an adult (other than the patient). Fathers with children present will be asked to remain in the waiting room until the end of the exam when they can be brought in to view the baby. Fathers unaccompanied by children are welcome to view the ultrasound.

ARTERIAL DOPPLER *

Upper extremities (No preparation)
Lower extremities (Nothing to eat or drink after midnight)
Renal arteries (Nothing to eat or drink after midnight)

*PLEASE FAX REQUISTION TO BOOK ARTERIAL EXAMS

 

ULTRASOUND (NO PREPARATION REQUIRED)

ECHOCARDIOGRAM

PRIOR VALVE REPLACEMENT
TYPE: ANNULAR SIZE:

ARM VENOUS DOPPLER

BILATERAL LEFT RIGHT

BREAST

BILATERAL LEFT RIGHT

CAROTID DOPPLER

HERNIA

VENTRAL UMBILICAL INCISIONAL

INGUINAL HERNIA

BILATERAL LEFT RIGHT

LEG VENOUS DOPPLER

BILATERAL LEFT RIGHT

MUSCULOSKELETAL

ACHILLES

LEFT RIGHT BILATERAL

ANKLE

LEFT RIGHT  

ELBOW

LEFT RIGHT  

FINGER

LEFT RIGHT SITE:

HIP

LEFT RIGHT  

KNEE

LEFT RIGHT  

SHOULDERS

LEFT RIGHT BILATERAL

SOFT TISSUE

SITE:

WRIST

LEFT RIGHT  

NECK

SCROTUM

THYROID

VEIN MAPPING

VEIN THERAPY CONSULT (Requires a separate letter of request)

OTHER:


 

 

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