Get Mibi Scan Requisition - Vancouver Island Health Authority

Filling out the MIBI Scan Requisition form is a crucial step in obtaining a myocardial perfusion scan through the Vancouver Island Health Authority. This guide provides comprehensive instructions to assist you in completing the form accurately and effectively.

Follow the steps to complete the MIBI Scan Requisition form online

1. Press the ‘Get Form’ button to access the MIBI Scan Requisition form and open it in your preferred editor.
2. Begin by filling out the ordering physician's name and billing number in the designated fields.
3. Provide the patient's personal health number (PHN) and print their full name clearly. Include the patient's signature and date.
4. Next, input the patient's primary phone number and optional fax number.
5. Indicate the patient's name, address, and contact numbers #1 and #2.
6. Select the patient's sex by checking the appropriate box and write in their date of birth in the format (dd/mm/yyyy).
7. Choose the patient's insurance provider from the list, noting if they are using MSP, WCB, ICBC, or specify other.
8. Answer if the patient uses a walker or wheelchair and provide information regarding their mobility status.
9. In the 'Reason for Exam' section, provide a clear and legible relevant clinical history. Ensure this information is accurately detailed.
10. Gather previous cardiac treadmill results and include a copy of the most recent ECG as required.
11. Indicate any contraindications to the treadmill stress test and supply details if any are noted.
12. Mention any contraindications to , specifying allergies as necessary.
13. Input the patient's height and weight measured in metric units, ensuring accuracy.
14. Review all provided information for completeness and accuracy before finalising.
15. Save your changes, and choose to download, print, or share the completed form as required.

Complete your MIBI Scan Requisition form online today.