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General Diagnostic Imaging

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Date of Issue
DD/MM/YY
Appointment Date
DD/MM/YY
General Diagnostic Imaging
|
REQUISITION
Patient Information Place patient label here
Name
DOB
DD/MM/YY
Male
Female
Address
City/Province Postal Code
Phone (Res)
Work Cell
AHC#
WCB#
Physician
Referring Physician
Address
Tel Fax
Additional report to:
Call/Fax emergency report to:
CD Copy
DIAGNOSIS OR RELEVANT HISTORY
Physician Signature
LMP Pregnant?
Yes
No
X-RAY (Walk-in)
Exam(s) Requested
BONE MINERAL DENSITOMETRY (BMD)
BMD (DEXA)
BREAST IMAGING
Complete Breast Imaging Assessment:
(Screening Mammogram and Ultrasound if Dense Breast)
Screening Mammogram
Ultrasound if dense breast (AWBU)
Diagnostic Mammogram
R
L
Diagnostic Ultrasound Breast and Axilla
R
L
BIOPSIES
Breast Biopsy
R
L
Thyroid Biopsy
R
L
VASCULAR ULTRASOUND
Venous DVT Leg:
R
L
Arm:
R
L
Carotid Arteries Other
Central Booking
(403) 541-1200
Fax
(403) 210-8377
ULTRASOUND
Complete Abdomen
Spectral Doppler
LOCATION
Renal (Kidneys & Bladder)
Pelvis
Hernia
Abdominal
Inguinal
Thyroid
Scrotum
Neck
Liver with SWE
Other:
OBSTETRICAL ULTRASOUND | MATERNAL FETAL MEDICINE
Complete OB Series (Dating/FTS/ Detailed/cervical
length screening)
Exclude cervical length screening
Dating / Viability
First Trimester Screening (11w2d-13w6d)
Routine Anatomical Screening (Approx. 19wks)
Includecervicallengthscreening
Fetal Assessment / Growth / Biophysical Prole (BPP)
Fetal Echo
Other:
To book exams required throughout the pregnancy, check all that apply
DIAGNOSTIC MSK ULTRASOUND
Rotator Cu/Shldr
Mass ____________________________________
Other Joint ___________________________________________________
Tendon ________________________________________________________
Ligament _____________________________________________________
MSK REGENERATION AND PERFORMANCE
Insured Uninsured
Ultrasound Guided Therapy:
SPECIFY BODY PART
Rotator Cu-lavage
Peripheral Nerve Injection:
SPECIFY NERVE
Tenotomy
SPECIFY TENDON
Prolotherapy (with consult)
Platelet Rich Plasma
Injection PRP
(with consult)
NUCLEAR MEDICINE
Bone Scan w/ Spect. CT
SpecicArea___________________________________________
Renal Scan
Function Diuretic for Obstruction Post Captopri
Thyroid Scan
HIDA Scan
Gallbladder Function Post-Cholecystectomy
Meckel’s Scan MUGA Scan
Appointment Required
LOCATION
SPECIFY TENDON
SPECIFY LIGAMENT
click to sign
signature
click to edit
PATIENT INSTRUCTIONS
General
• Please arrive 15 minutes in advance of your appointment time.
• Conrming your identication is essential to ensure accurate medical records and for
your protection and security.
• You will be asked at EACH VISIT to provide a VALID HEALTH CARE CARD and
PICTURE ID.
• If you do not have your card you may be asked to return for your examination.
• Please bring your requisition with you.
• Phone to cancel if unable to keep booked appointment.
• Please notify reception if you are diabetic.
• Patients suspecting pregnancy should consult their physician before exam date.
Ultrasound
OBSTETRIC, PELVIC (includes Kidneys & Urinary Bladder) & PROSTATE E X AMS;
PELVIC or URINARY BLADDER combined with ABDOMINAL EXAM
Drink four (4) 8-ounce glasses of water, (patients under 80 lbs. and MFM patients drink
only 2 glasses) completed 1 hour before your appointment. DO NOT empty your bladder
until the exam is completed. If absolutely necessary, bladder may be partially emptied*.
(ObstetricalPatients:Pleasenotethatifyouarebeyond28weeks,youdonothavetoll
your bladder and we recommend you eat 1/2 hour prior to study.)
ABDOMINAL EXAM (includesLiver,Kidneys,Gallbladder,Spleen,Pancreas
and Abdominal Vessels)
DO NOT EAT for 6 hours prior to exam. Clear uids allowed. No milk or cream.
Mammography
Deodorants, perfumes, antiperspirants, lotions and body powder can produce abnormal
shadows on a mammogram. Do not use them on the day of the mammogram and, if
possible, take a shower before to wash o any residue. Wear a 2-piece outt if possible. If
you have premenstrual tenderness, you may delay your appointment until tenderness has
subsided. Avoid caeine for 24-48 hours.
Bone Densitometry – DEXA
Wear loose tting clothing without zippers or metal. No barium studies one week prior to
this exam.
Nuclear Medicine
Type of Study Preparation Length
Bone & Joint None 3 hrs*
Renal Scan Drink Water
†
1-2 hrs
MUGA Heart Scan None 1 hr
Thyroid Scan None 30-60 mins
HIDA Scan 4 hr fast 2 hrs
Meckel’s Scan 6 hr fast 1 hr
*
Injection followed by 1 hour of imaging 2-3 hours later.
†
Drink four (4) 8-ounce glasses of water, (patients under 80 lbs.only 2 glasses) during the 2 hours
before your appointment.
SEPARATE REQUISITIONS FOR:
Pain Management & Spine Interventional, Pediatric Ultrasound, or MRI
AvailableasPDFdownloadsonourwebsite,efwrad.com,orcall(403)717-1816
LOCATIONS
WALK-IN GENERAL X-RAY LOCATIONS
NW
NW
NW
SW
SW
SE
AIRDRIE
NORTHWEST CALGARY
Advanced Medical Imaging Centre
100, 2000 Veterans Place NW, Calgary, AB T3B 4N2
Phone: (403) 541-1200 Fax: (403) 210-9088
Advanced Spinal Care Centre North
201, 2000 Veterans Place NW, Calgary, AB T3B 4N2
Phone: (403) 244-3700 Fax: (403) 210-8382
Beddington
200, 8120 Beddington Blvd. NW, Calgary, AB T3K 2A8
Phone: (403) 541-1200 Fax: (403) 210-9080
Calgary Maternal Fetal Medicine Centre
305, 1000 Veterans Place NW, Calgary, AB T3B 4M1
Phone: (403) 289-9269 Fax: (403) 210-9058
Foothills Professional Building
148, 1620 - 29th Street NW, Calgary, AB T2N 4L7
Phone: (403) 541-1200 Fax: (403) 210-9059
MSK Regeneration and Performance Centre
201, 2000 Veterans Place NW, Calgary, AB T3B 4N2
Phone: (403) 541-1200 Fax: (403) 210-8377
NORTHEAST CALGARY
Sunridge Clinic
130, 2851 Sunridge Blvd. NE, Calgary, AB T1Y 7B5
Phone: (403) 541-1200 Fax: (403) 210-9956
SOUTHWEST CALGARY
Gulf Canada Square
300, 401 - 9th Avenue SW, Calgary, AB T2P 3C5
Phone: (403) 541-1200 Fax: (403) 210-8392
Nuclear Cardiology
210, 1016 - 68th Avenue SW, Calgary, AB T2V 4J2
Phone: (403) 541-0033 Fax: (403) 210-8389
Prostate Cancer Institute
Rockyview General Hospital
6500, 7007 - 14th Street SW, Calgary, AB T2V 1P9
Phone: (403) 541-1200 Fax: (403) 210-8388
Southport Atrium Clinic
A8, 10333 Southport Road SW, Calgary, AB T2W 3X6
Phone: (403) 541-1200 Fax: (403) 210-9081
SOUTHEAST CALGARY
EFW Radiology Seton
212, 3883 Front Street SE, Calgary, AB T3M 2J6
Phone: (403) 541-1200 Fax: (403) 210-8377
Advanced Spinal Care Centre South
212, 3883 Front Street SE, Calgary, AB T3M 2J6
Phone: (403) 244-3700 Fax: (403) 210-8382
Quarry Park Maternal Fetal Medicine
130, 109 Quarry Park Blvd. SE, Calgary, AB T2C 5E7
Phone: (403) 289-9269 Fax: (403) 210-9961
AIRDRIE
EFW Radiology Airdrie Clinic
204, 836 - 1st Avenue NW, Airdrie, AB T4B 0V2
Phone: (403) 541-1200 Fax: (403) 210-9052
MRI Booking: (403) 541-1200 Fax: (403) 210-8377
MFM Booking: (403) 289-9269 Fax: (403) 210-8381
Film and Report Line: (403) 717-1816 Fax: (403) 541-0006
(403) 541-1200 efwrad.com Fax: (403) 210-8377
EFW is a proud partner of:
Officialdiagnosticimagingproviderfor:
TM
Advanced Medical Imaging Centre
Beddington
Foothills Professional Building
Gulf Canada Square
Southport Atrium Clinic
EFW Radiology Seton
EFW Radiology Airdrie Clinic
Notice: The personal health information that you provide to EFW is collected, used and disclosed in accordance with the provisions of the Health Information Act (HIA), and
is used to provide diagnostic, treatment and care services to you, and to bill Alberta Health Care for services provided. For more information, please contact the EFW Privacy
Ocer at (587) 470-6449.
8272018
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General Diagnostic Imaging

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Completed 17 February 2021

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