Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in the patient information section, including details such as your medical record number (MRN), date of birth (DOB), health card number, last name, and first name. Specify the language for an interpreter if needed and indicate any mobility restrictions.
3. In the patient information section, select the appropriate payment option such as self-pay, IFH, or WSIB claim. You should also identify your gender or specify if you identify as transgender or intersex.
4. Provide contact information, including mobile, work, and home phone numbers, as well as your street address, city, postal code, province, and country.
5. In the exam information section, enter the date of request, specify the exam requested, and include relevant clinical information.
6. Complete the medical history section by indicating any relevant history, current medications, and allergies. Check off applicable boxes for conditions such as hypertension, diabetes, and renal disease.
7. Fill out the blood work section, ensuring results are dated within 30 days. Provide necessary values including creatinine, INR, platelets, and PTT.
8. Seek the appropriate signatures in the signature section. Ensure both the referring physician and radiologist signatures are added along with their respective details.
9. Once completed, review the form for accuracy. You may then save changes, download, print, or share the form as needed.

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