Get Ct Scan Requisition - Ross Memorial - Rmh

Filling out the CT scan requisition form for Ross Memorial Hospital is an essential step in ensuring patients receive timely and effective care. This guide will provide comprehensive instructions to help users complete the form accurately and efficiently online.

Follow the steps to successfully complete your CT scan requisition form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by circling the appropriate option for the patient's visit type: OP (outpatient), IP (inpatient), or Emerg (emergency). Also, fill in the room number and extension if applicable.
3. Enter the patient’s full name, address, city, phone number, date of birth, and OHIP number in the designated fields.
4. Indicate if the patient is covered by WSIB by selecting 'Yes' or 'No' and provide the claim number if applicable.
5. Complete the isolation precautions section by checking the appropriate option: Not Required, Airborne, Droplet, or Contact.
6. Fill in the MRN (medical record number) and the names of the referring doctor, family doctor, and any other specialists involved in the patient's care. Provide the fax number of the referring doctor as well.
7. Record the patient's weight and height in the respective fields.
8. Answer the questions regarding any adverse reactions to X-ray dye, whether the patient is on dialysis, and if the patient is diabetic by selecting the corresponding 'Yes' or 'No' options.
9. State the patient's creatinine level with the date for record-keeping purposes.
10. Specify the area(s) to be scanned and who will be conducting the CT scan along with the planned date.
11. Provide clinical information or differential diagnosis to assist with the procedure's justification.
12. The physician must sign and date the form to verify that all information is accurate and complete.

Complete your CT scan requisition form online to ensure prompt medical attention.