19031 (Rev2017-06)

< Fax to Diagnostic Imaging; fax numbers listed athttp://www.albertahealthservices.ca/diagnosticimaging

< Urgent/Emergent requests must bediscussed by direct consultation withthe radiologist

Preferred Facility

Specific anatomical area to be examined/name of exam

Relevant clinical history/presumptive diagnosis

Clinical question to be answered

Patient label here or information below is required

Last Name First Name

Birthdate (yyyy-Mon-dd) Gender

Address (street, city, province, postal code)

PHN Daytime Phone

Inpatient location WCB Claim Number

Condition No Yes If Yes:

Isolation Precautions o o Specify type:

Allergies o o Specify:

Medications o o Specify:

Breastfeeding o o n/a

Pregnant o n/a o o Date of LMP: Date of BHCG:

Diabetes o o n/a

Mechanical lift/transfer required o o

Specify:

Research Study o o Study name: Study Number:

Patient type o Outpatient o Emergency o Inpatient ► Patient Location:

Previous Treatment

Treatment No Yes If Yes:

Chemotherapy o o Where: When:

Radiation Therapy o o Anatomical location: When:

Surgery o o Anatomical location: When:

Nuclear Medicine

Request

Department Use Only Date format: yyyy-Mon-dd - Time format: hh:mmRadiologist Protocol

Date Received Time Received Appointment Date Appointment Time

Relevant Previous Imaging StudiesLocation Type Date (yyyy-Mon-dd) Attached copy

o No o Yes

Current Patient Condition Weight ______ o Kg o lbs Height ______ o cm o in

Referring Physician (PRINT first and last name) Physician Phone(required)

Physician Fax(required)

Contact Number for CriticalTest Results (required)

Signature Date (yyyy-Mon-dd) Copy to Physician (first and last) Copy to Fax