Name: _________________________________________

Address: _______________________________________

Department of Diagnostic Imaging

CT City: _____________________ Postal Code: __________
Health Card No.: _________________________________
Date of Birth: (DD/MM/YYYY): ______________________
Telephone #: (H) _________________________________
Telephone #: (C) _________________________________
Request for CT Consultation - Outpatients
Appointment:
 Brampton Civic Hospital Fax: 905-494-6618 Date: ______________________________
 Etobicoke General Hospital Fax: 416-747-3610
 Peel Memorial Urgent Care Centre Fax: 905-863-2475 Time: ______________________________
Telephone: 905-494-6688
Appointments will be booked at the site with the first available appointment, providing the patient with the shortest wait time
Fax, mail or drop off requisition. Appointment will be given by telephone or mail notification.

Examination Requested:

Head Chest Abdomen Pelvis Vascular

 Routine  Routine  Routine  Routine  Femoral Runoff
 Paranasal Sinuses  Low Dose Non-Contrast  Renal Colic  AAA
 ______________  High Resolution  Liver  Carotid
 Pulmonary Embolus  Pancreas Musculoskeletal  Circle of Willis
Neck  Cardiac  Kidneys  Cervical (Levels)  Thoracic Angio
 Routine  Coronary Calcium  Adrenals  Thoracic (Levels)  Subclavian
 ______________ Scoring  Urogram  Lumbar (Levels)  _______________
 _______________  Enterogram  Hips
 Colonography  Bony Pelvis
 ___________  _____________

Clinical History: __________________________________________________________________________________________________

_________________________________________________________________________________________________________________
Previous Imaging Studies and Findings (CTs, MRI, Ultrasound, etc.) ______________________________________________________
_________________________________________________________________________________________________________________
Creatinine: ________ eGFR: _________ (Within last 3 Months) Date: _____________ Patient Weight: __________(Kg)
 If eGFR less than 30 and contrast indicated then give 0.9% NaCl 300 mL IV over 1 hour pre-CT and
0.9% NaCl infuse at 350 mL/h x 2 hours post-CT

1) AGE 70 OR UP YES NO 4) Is patient on dialysis? YES NO

2) Is patient diabetic? YES NO If yes to dialysis: urine output? YES NO
IF YES: Is patient taking any medication containing Days & Time: ______________________
Metformin? YES NO 5) Has patient had previous contrast injection? YES NO
For eGFR under 30 - Metformin containing drugs should 6) Allergy to contrast dye YES NO
be held following IV contrast administration and serum
creatinine repeated 48 hrs after CT and verified before IF YES to known contrast allergy the requesting physician
restarting. The patient will be given an information sheet is responsible for organizing the premedication prior to
after the CT scan regarding this. the patients CT scan.

3) a) History of renal risk factors, such as single kidney, Please follow the Pre-medication instructions below:
Single kidney, Renal CA/Transplant/Surgery
YES NO Prednisone 50mg P.O. 13 hours, 7 hours, 1 hour pre-CT
Plus Benadryl 50 mg P.O. 1 hour pre-CT
b) History of myasthenia gravis: YES NO
DI Use Only
P1 P2 P3 P4
NOTE: If Yes to Question 1, 2 or 3a order Serum creatinine & fax results
Protocol + Priority

Physician Name (Print) ___________________________Telephone _________________

Physician Signature _____________________________ Date ______________________

___
Please forward requisition to Diagnostic imaging Department at William Osler Heath System Corporate Bookings
***NOTE: Incomplete requests including missing serum creatinine/eGFR will be returned, resulting in delay of booking***
Form # 8100-061 – Stores # 048759 (27/03/2017)