Get Ct/mri Request For Examination Form

Filling out the CT/MRI request for examination form online is a critical step in ensuring you receive the necessary imaging services. This guide provides a clear, step-by-step approach to help you complete the form accurately and efficiently.

Follow the steps to complete the form with ease.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Provide the patient's personal information, including their last name, first name, address, date of birth, city, province, postal code, and phone number.
3. Enter the referring physician's details, such as their name, address, phone number, fax number, and provider ID. Ensure that you include the physician's signature and health card number.
4. Indicate whether the patient consents to have appointment information disclosed via telephone by selecting 'Yes' or 'No'.
5. In the 'Area to be examined' section, fill out any specific areas that require examination. Provide clinical history or diagnosis if applicable.
6. Complete the section for any previous relevant exams, including the date of the accident if this is a WSIB exam, and fill out the WSIB claim number.
7. For CT patients, indicate if there is a history of kidney disease, diabetes, reactions to IV contrast, or other specific health considerations by checking 'Yes' or 'No'.
8. For MRI patients, complete the necessary questions regarding past MRIs, potential metal in the eye, kidney disease, and claustrophobia.
9. Patient signature and date are required at the bottom of the form to confirm consent.
10. Finally, review the completed form for accuracy, then choose to save changes, download, print, or share the form as needed.

Start filling out your CT/MRI request for examination form online today for a smoother appointment.