Request For Examination
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1
2REQUEST FOR EXAMINATION
X-ray, Ultrasound
PATIENT INFORMATION
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Patient’s Last Name
First Name
Sex ( M / F )
Date of Birth
( MM / DD / YYYY )
Address
City
Postal Code
Home Phone
Business Phone
| | | | | | | | | | |
Health Card Number
INSURANCE
APPOINTMENT INFORMATION
Please bring this form with you. Your Health Card is required for every visit. Please arrive 15 minutes before your appointment.
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MSP
ICBC
Appointment Date:
(Please give 24 hours notice if you are unable to keep this appointment)
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Private
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WCB
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Other:
Appointment Time:
(If you are late for this appointment, you may have to reschedule)
X-RAY (No Appointment)
ULTRASOUND (By Appointment Only)
Examination requested:
Examination requested:
FLUOROSCOPY (By Appointment Only)
HYSTEROSALPINGOGRAM
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UGI
What was the first day of your period? (First day of full flow).
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UGI with follow-thru
Month/Day:
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Small Bowel
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Barium Enema
PHYSICIAN INFORMATION
REFERRING PHYSICIAN OFFICE STAMP
Name of Referring Physician
MM/DD/YYYY
Practitioner Number
Physician Signature
Copy to:
PERTINENT CLINICAL INFORMATION (If patient is diabetic, notify at time of booking. Indicate any known/suspected communicable infectious diseases)
Verbal
For timely interpretation of this examination, please include clinical information:
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24-hour notice required to cancel appointment or $75 charge will be billed to patient.
IMG-VAN-02
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Parent category: Medical