Please complete both pages and fax to (587) 000-0001
HIA PROTECTED
Protected under the Health Information Act (HIA), Alberta. Collected solely for diagnostic imaging and handled in accordance with HIA custodian obligations.
✓ No data saved to server
Patient Information
Gender
Clinical History
Area(s) to be imaged and detailed clinical history. Please be as specific as possible. Attach relevant prior reports.
Page 2 of 2 — CT Scan, Private Pay & Referrer Information
Both pages must be submitted together
HIA PROTECTED
Protected under the Health Information Act (HIA), Alberta. Collected solely for diagnostic imaging and handled in accordance with HIA custodian obligations.
✓ No data saved to server
Continuation — Page 2 of 2:
Patient Last Name:
First Name:
Date of Birth:
CT Scan — Wide Bore | Select Exam(s)
CT Safety Assessment — Please Complete All Fields
Known allergy to contrast?
Renal function (<90 days)?
GFR:
Other allergies?
On Dialysis?
Pregnant?
Last Menstrual Period (if applicable)
LMP:
Health Assessment Programs — Private Pay
MRI Screening
CT Screening
Genetic Screening Add-On
Referrer Information
Report Options
Reports are delivered by fax to the referring physician within standard turnaround. STAT phone reports are available for urgent clinical decisions — please call (587) 000-0000.
Note: This requisition is valid for 12 months from the date of request. Please attach relevant prior imaging reports where applicable. Both pages of this requisition must be submitted together. For urgent bookings please call directly.