Kitchener / Waterloo - Oxford Medical Imaging

If you are completing this form our online, please email it to [email protected] or fax to 519–576–8768
385 Frederick St, Unit 20A
Kitchener ON N2H 2P2
P: 519–749–9555
F: 519–749–9312
421 Greenbrook Dr, Unit 23A
Kitchener ON N2M 4K1
P: 519–569–8592
F: 519–569–7286
Medical Centre
430 The Boardwalk, Suite 104
Waterloo ON N2T 0C1
P: 519–576–8760
F: 519–576–8768
REQUEST FOR EXAMINATION FORM
RESET
See reverse for maps, preparatory instructions and location.
Appointment
DAYMONTHYEAR
Location
rrive at least 15 minutes before your appointment and bring this form and your OHIP card.
A
If you arrive late, you may be rebooked at another time and date.
Patient’s Last Name
Patient’s First Name
Address
Date of Birth (DD | MM | YYYY)
City
Prov.
Postal Code
Phone #
Mobile #
Health Card #
Referred By
Address
Phone #
Fax #
Physician’s Signature:
CC Reports to:
CPSO #:
Date:
Clinical History (REQUIRED) q STAT q VERBAL
Contact #
DIGITAL ULTRASOUND (By appointment only)
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
GENERAL ULTRASOUND
qqAbdomen
qqAbdomen/pelvis complete
qqAbdomen/pelvis (KUB)
SMALL PARTS
qqFace
qqThyroid and neck
qqNeck
qqBreast (mR mL mBil)
qqChest
qqGroin (mR mL mBil)
qqTestes/Scrotum
qqOphthalmic
qqSoft tissue/lump
OBSTETRICAL
qqDating
qqCombined NT + Anatomic
FEMALE PELVIS
qqWoman’s Yearly Exam
qqPelvis (includes transvaginal
unless contraindicated)
MALE PELVIS
qqPelvis (transabdominal,
includes bladder, prostate,
seminal vesicles)
qqProstate (transrectal includes
transabdominal)
US GUIDED PROCEDURES
qqSonohysterogram
qqThyroid FNA biopsy
qqOther FNA
qqUS guided injection
MUSCULOSKELETAL
(Includes corresponding X-ray)
(11–14 wks) + Anatomic (18–20 wks)
DIGITAL X-RAY
CHEST
qqChest (2 views)
qqRibs & chest P.A.
(mR mL mBil)
qqSternum
qqChest visa
ABDOMEN
qqPlain film (KUB 1 view)
qqAcute (2 views) + PA chest
GASTRICS (BY APPOINT. ONLY)
qqBarium swallow
qqUGI series (Double contrast)
qqUGI & SBFT
qqSmall bowel follow-through
qqBarium enema (Double contrast)
Turn over for patient instructions
SPINE & PELVIS
qqCervical spine
qqThoracic spine
qqLumbar (L/S) spine
qqL/S spine, pelvis & S.I. joints
qqSacrum & coccyx
qqS.I. joints
qqPelvis
www.oxfordmedicalimaging.ca
|
Walk-in appointments accepted until 5 pm
HEAD & NECK
qqSoft tissue neck
qqSkull
qqSinuses
qqOrbits for MRI
qqFacial bones
qqNose
qqMandible
qqT.M. joints
qqAdenoids
qqMastoids
SKELETAL SURVEY
qqMetastatic series
qqArthritic series
qqBone age
LOWER EXTREMITIES
R
L
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
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
q Sternoclavicular joints
q A.C. joint
1 2 Scapula
q
3 4
2 3 4
5
5
q Humerus
q Elbow 1
q Forearm
q Wrist
q Scaphoid
q Hand
q Fingers # 1 2 3 4 5
SAVE AS
NT

Anatomic

qqNT (11–14 wks)
qqAnatomic (18–20 wks)
qqFetal growth follow-up
qqBiophysical profile
qqTwin Series1
qqHigh Risk Twin Series2
qqFollicular monitoring
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
q
q
q
q
q
q
q
q
q
q
q
q
Bil
q Shoulder
q Arm
q Biceps
q Elbow
q Wrist
q Hand
q Finger
q Hip
q Thigh
q Knee
q Popliteal fossa
q Calf
q Ankle
q Achilles tendon
q Foot
q Toe
q Plantar fascia
q Other
qNo X-ray req’d
DIGITAL MAMMOGRAPHY (FFDM)
By appointment only. See reverse for maps, preparatory
instructions and location.
Lesion (please indicate site on image)
Previous: qYes qNo
Where:
Right
Left
When:
Clinical info:
WOMAN’S YEARLY EXAM
Bil
1 2 3 4
q Hip
5
q Femur
q Knee
q Tib. & fib.
q Ankle
q Foot
q Calcaneus
q Toes # 1 2 3 4 5
1
5
qqIncludes all listed below
• US female pelvis
• US abdomen
• US thyroid
• US breast
• Digital mammogram
• BMD (if applicable)
2
3
4
YOUR HEALTH IS OUR IMAGE
BONE MINERAL DENSITOMETRY (BMD)
By appointment only. (No contrast or radioactive exam the
previous week).
qqBaseline (1st BMD)qLow risk3 qHigh risk (Every year)
Previous (required): qYes qNo
Where:
When:
Indication:
F01e1404v02

Download Report