Dr Dan Gill
MD, FRCPC
E S R
Dr Mohamed Tabib
M.B.B.ch, FRCPC
11811 Tecumseh Rd E, Suite 112
Tecumseh ON N8N 4M7
519–979–2255 | Fax: 519–979–3782
ERIE ST CLAIR RADIOLOGY
Dr Fareed Denath
MB. ChB., FRCPC
2224 Walker Rd, Suite 150
Windsor ON N8W 5L7
519–254–7553 | 519–254–7554
Fax: 519–254–7936
RADIOLOGY REQUISITION FORM
RESET
See reverse for maps, preparatory instructions and location.
Appointment
DAYMONTHYEAR
Address
Date of Birth (DD | MM | YYYY)
City Prov.
Postal Code
Phone #
Cell Phone #
Health Card #
Referred By
Address
Phone #
LOW DOSE DIGITAL X-RAY IMAGING
SAVE AS
Please arrive 10 minutes before your appointment and bring your OHIP card. If you are unable to keep
your appointment, please give us 24-hour notification.
Patient’s First Name
2425 Tecumseh Rd E, Suite 108
Windsor ON N8W 1E6
519–258–7248 | Fax: 519–258–9408
X-RAY | ULTRASOUND | BMD
Location
Patient’s Last Name
Dr Winston Ramsewak
MD, FRCPC
Fax #
Physician’s Signature:
DIGITAL ULTRASOUND
By appointment only. See reverse for maps, preparatory
instructions and location.
GENERAL ULTRASOUND
qqFace
qqOphthalmic
{{Biometry (mR mL mBil)
{{B-mode (mR mL mBil)
qqNeck
qqThyroid
qqBreast (mR mL mBil)
qqChest (pleural effusion)
qqAbdomen
qqAbdomen and Pelvis
qqKidneys
qqKidneys/Bladder
qqGroin (mR mL mBil)
qqTestes/scrotum
FEMALE PELVIS
qqPelvis (includes transvaginal
CC Reports to:
Clinical History (REQUIRED) q STAT q VERBAL
unless contraindicated)
Contact #
MALE PELVIS
qqPelvis (transabdominal,
includes bladder, prostate,
seminal vesicles)
qqProstate (transrectal, includes
bladder & seminal vesicles)
OBSTETRICAL
qqCombined NT + Anatomic
(11–14 wks) + Anatomic (18–20 wks)
DIGITAL X-RAY
HEAD & NECK
qqSoft tissue neck
qqSkull
qqSinuses
qqOrbits for MRI
qqFacial bones
qqNose
qqMandible
qqT.M. joints
qqAdenoids
qqMastoids
ABDOMEN
qqPlain film (K.U.B. 1 view)
qqAcute (2 views) + PA chest
CHEST
qqChest (2 views)
qqRibs & chest P.A.
(mR mL mBil)
qqSternum
qqOther
X-RAY | ULTRASOUND | BMD
SPINE & PELVIS
qqCervical spine
qqThoracic spine
qqLumbar (L/S) spine
qqL/S spine, pelvis & S.I. joints
qqSacrum & coccyx
qqS.I. joints
qqPelvis
SKELETAL SURVEY
qqMetastatic series
qqMultiple myeloma series
qqArthritic series
qqBone age
qqScoliosis series
UPPER EXTREMITIES
R
L
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
Bil
q Shoulder
q Clavicle
qSternoclavicular joints
q A.C. joint
q Scapula
q Humerus
q Elbow
q Forearm
q Wrist
q Scaphoid
q Hand
qFingers # 1 2 3 4 5
NT

Anatomic

qqDating
qqNuchal lucency (11–14 wks)
qqAnatomic (18–20 wks)
qqFollow-up for assessment
of fetal growth
qqBiophysical profile
qqCervical length
qqMCA dopplers/BPP
qqTwin series+
qqHigh risk twin series++
qqHigh risk
qqFollicular monitoring
R
L
q
q
q
q
q
q
q
q
Bil
q Hip
q Femur
q Knee
q Tib. & fib.
q Ankle
q Foot
q Calcaneus
qToes # 1 2 3 4 5
S TAT E - O F - T H E - A R T D I G I TA L I M A G I N G
(Includes an X-ray unless
contraindicated)
R
L
Bil
q Shoulder
q Arm
q Biceps
q Elbow
q Wrist
q Carpal tunnel
q Hand
q Finger
q Hip
q Thigh
q Knee
q Calf
q Ankle
q Achilles tendon
q Foot
q Toe
q Plantar fascia
q Popliteal fossa
qSoft tissue/
superficial mass
q q q Other
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
qq No X-ray req’d
DOPPLER VASCULAR
STUDIES
qqCarotid arteries
qqRenal arteries
qqAorta
qqPortal venous hypertension
qqPeripheral arterial legs (ABI)
qqPeripheral arterial arms
qqPeripheral venous legs
(DVT) mR mL mBil
qqPeripheral venous arms
(DVT) mR mL mBil
qqVaricose vein assessment
qqOther
BONE MINERAL DENSITOMETRY (BMD)
LOWER EXTREMITIES
q
q
q
q
q
q
q
q
MUSCULOSKELETAL
By appointment only. (No contrast or radioactive exam the
previous week).
qqBaseline (1st BMD)qLow risk* qHigh risk (Every year)
Previous (required): qYes qNo
Where:
When:
Indication:
*(3 years after first exam, then every 5 years)
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