Diagnostic Imaging Request For Mri Scan Form - The Scarborough Hospital
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1Diagnostic Imaging
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REQUEST FOR MRI SCAN
General Campus
Birchmount Campus
Fax to one Campus only
3050 Lawrence Avenue East
3030 Birchmount Road
Scarborough, ON M1P 2V5
Scarborough, ON M1W 3W3
In Patient Unit: ______________
Tel: (416) 438−2911 ext 6170 Fax 416−431−8157
Tel: (416) 495 2480 Fax 416−495−2619
Gender
Last Name
First Name
Date of Birth
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City
Postal Code
Address
Phone (Day)
Phone (Evening)
Phone (Other)
Hospital Unit Number
Health Card Number
Email Address
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WSIB Examination?
Yes
Claim No:________________________________ Approved by:___________________ On ____________
AREA TO BE EXAMINED − PLEASE BE SPECIFIC − TO BE
INCOMPLETE FORMS WILL BE RETURNED
PATIENT SCREENING−TO BE COMPLETED BY REFERRING
COMPLETED BY REFERRING PHYSICIAN
PHYSICIAN
______________________________________________________
1. Does the patient require sedation? (to be provided
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by referring physician)
Y
N
Clinical Information/Working Diagnosis:
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2. Does your patient require mobility assistance?
Y
N
3. What is the patient’s height & weight? _______ cm _______ kg
4. Is the patient pregnant?
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Y
N
5. Is the patient breastfeeding?
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Y
N
6. Does the patient have a history of the following?
− Metal cutting, welding or grinding (work, home,
school)
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Y
N
Referring Physician Information:
− Injury to eye(s) or face with/from a piece of metal
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Y
N
Name:
− Orbital or cataract surgery (if yes, provide
location where surgery performed)
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Y
N
− Feraheme/Ferumoxytol injection (include date of
Address:
injection below)
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Y
N
− Recent gastroscopy or colonoscopy (provide
report to r/o vascular clips)
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Y
N
7. Does the patient have any of the following?
Postal Code:
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− Pacemaker, Neurostimulator, Aneurysm Clip
Y
N
− Heart valve prosthesis
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OHIP Billing Number:
Y
N
− Intraventricular shunt ( provide implant details)
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Y
N
− Cochlear, middle ear implant (provide surgical
Phone:
Fax:
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report)
Y
N
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− Pessary or penile implants
Y
N
Copies of the report to be sent to:
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− Embedded shrapnel or bullet fragments
Y
N
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− Orhopaedic implants (screws, joints)
Y
N
Referring Physician Signature:
− Surgical clips, staples, wires, embolization coils
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Y
N
− Transdermal skin patches (ie. Nitro, Hormone)
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Y
N
− Body piercings (remove prior to arrival)
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Other tests to date:
Y
N
− Tattoos or tattooed eyeliner, dental
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implants/appliances
Y
N
MRI
Ultrasound
CT
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− Surgery of any kind
Y
N
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X−Ray
Nuclear Medicine
Angiogram
Provide details for all questions that you responded YES to:
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Mammography
ATTACH COPIES OF ALL RELEVANT TEST REPORT
IMAGING PROTOCOL− TO BE COMPLETED BY RADIOLOGIST
ASSESSMENT OF RISK FACTORS FOR NEPHROGENIC SYSTEMIC
Priority Code
1
2
3
4
FIBROSIS − TO BE COMPLETED BY REFERRING PHYSICIAN
8. Is the patient:
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− Over 60 years of age?
Y
N
Protocol Details ______________________________________
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− On dialysis?
Y
N
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Breast Cancer
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Cancer
Other
− Diabetic or hypertensive?
Y
N
− Acutely ill or hospitalized?
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Y
N
Radiologist review
Y
Contrast
Y
− Taking nephrotoxic medications? (loop diuretics, amphotericin B,
Aminoglycosides, vancomycin, non−steroidal anti−inflammatory
Signature: ____________________________________________
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drugs, cancer and immune suppressant)?
Y
N
9. Does the patient have a history of:
SCREENING REVIEW − TO BE COMPLETED AT TIME OF SCAN
− kidney disease, kidney failure or transplant,
BY TECHNOLOGIST
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single kidney, liver disease or transplant?
Y
N
− cardio−vascular disease, hypertension, congestive heart
disease, cardiac or peripheral vascular disease)?
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Patient: ________________________________________________
Y
N
If any of the answers to #8 or #9 are YES and intravenous
contrast material will definitely be given, the following information
Technologist: _______________________
Date: ____________
MUST be provided (if uncertain, Diagnostic Imaging will instruct
after deciding the imaging protocol):
Hospital Scheduling Office Use Only
Serum Cr: __________________ or eGFR:_________________________
Request Logged: _______________________________________
(within past 12 weeks)
Scheduling Code: _______________________________________
Date of blood test: _____________________________________________
Appointment: ___________________ @ __________________hrs
Patient ethnicity: _______________________ (required for eGFR calculation)
Distribution: Chart Copy
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