Follow the steps to complete the form with ease.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information in section A. Fill in the Medical Record Number (MRN), Date of Birth (DOB), Health Card number, and other personal details such as last name and first name. Indicate the payment method by selecting one of the options provided.
3. Input the patient’s street address, city, province, postal code, and country. Then, indicate the preferred method of communication by filling in the mobile, home, and work contact details.
4. Complete the required patient information, including any relevant pregnancy status, weight, and height.
5. Move to section B to fill out the exam information. Enter the date of request, select the side (right, left, bilateral) if applicable, and specify the exam requested. Include any necessary clinical information to support the examination.
6. In section C, provide the ordering physician’s name and signature. Ensure to print this information clearly. You may also add the name of the person to copy and the required CPSO number and billing information.
7. Once all sections are complete, you can save changes to your form. Additionally, options to download, print, or share the form will be available for your convenience.

Complete your documentation online today for a smoother healthcare experience.