GNMI MISSISSAUGA MEDICALIMAGING | MRI|CT|ULTRASOUND | XRAY PatentLactNane Patient Name Home Prone celProne sex MIE tyyoate 00 fv J 24hour oupe Diwsie Cl xeronrtinepaey Version Code “ppenenest Date ‘Aapatinent Tire Oct Omr Doctor's Signature Cite Leeaee) ves No oa Creatinne/GER levels withinlast 6 mos: cer bed Lastmenstrateyele 0 fi [ ‘Prostate 1 Coronary TA &Caleium Scoring FOR ALL PATIENTS History of kidney disease? 1) Coronary Calcium Scoring GENERAL, Abdomen (1 Pelvis-transvaginal (Pelvis transabdominal Renal Bladder CI PVRPost Void Residual Ci Transrectal Prostate CAMA Screening (Abdominal Wall/ emia (1 Inguinal Canal Scrotum (i Thyroid andNeck FEMALE PELVIS Pelvis transvaginal Pelvis -transabdominal MALE PELVIS. 1 Pelvis~transabdominal blader and prostate A Prastate- transrectal BREAST ULTRASOUND OL OR Bilateral Pescelistkronn erie: Previous suger: FOR CT PATIENTS: YES No Prviseactont oa FOR MAI PATIENTS (obecarpated wats Alergytogadaliiumcantast? NaveyouhadapreviousMA? Has meta ver goneinto your eye? Doyouhave any kidney disease? Areyouon dialysis? a Areyouclaustrophobic? a cotrst? aaggaa ‘ficial Cardiac Valve Cardiac Pacemaker clear Inplants CoiySeents Neurostimdator Retained acing Shrapoe!/Bult Qoog0000 Qaggacaa ete ypeimpantnede UcTrasouNo: Hevestoaypin Ths req suchas oselisedon te cerequredto apparent or $5 charge bled Peed zn farm canbe taken to ay ceced fly providing heatnare se The Emerald Centre 10Kingsbridge Garden Circ Phone: 905-568-3768 Fax 905-568-0941 FREE PARKING wwwgnmica info@gnmica eferingPhysicanName CompanyName lepsties OES ON CLINICAL HISTORY - EXAM REQUESTED *Please specify area to be examined aie) OF MABeeast Screening (not O3SP righ ik) 1 MAL Breast Implant for rupture only cHEsT A chestPA&LAT ORbs OROLOB (includes PAchest) Sterna-Claw ‘ABDOMEN CVARDSeries 1 KUB (singleview) UPPER EXTREMITIES 8 Bilateral BLR 900 Hane 350 Waist 3100 Elbow 1100 Shoulder 200 Forearm 9100 Humerus aoa Sternum HEAD & NECK. C1Soft TssueNeck skal A Sinuses MUSCULOSKELETAL BeBiloteral BL R Shoulder = 0 Elbow ooo Wrist oo990 Hand ooo Knee ogo PoplitealFossa A Achilles Tendon OO. Ankle oo90 Foot ooo PlantarFascia OOO Lumps &Bumps 1.0 Hp ooo OBSTETRICS Facial Bones Nese (Mandible orbits A TMoints SPINE & PELVIC He aR aL A Cerweal Spine 0 Thorac Spin Lumbar (L/S}Spine Pelvis A SLJoints 1 Sacrum/Coceyx 1 Scoliosis Clavicle FOO AC Joins 100 Seapuia 3100 Seaphois 1010 Finger LOWER EXTREMITIES B~Bilteral BLA AGO Knee D100 Ankle 1.00 Foot 900 Hip 91.00 Femur 900 There. 100 Kee 1010) Toe 12345 2345 18-20 weeks Fetal Growth High Risk (Biophysical Profile (BPP) Nuchal Transtucency EsTS (iilaweeks) [1 Othe MRI & CT: FAX COMPLETED REQUISITIONS TO 905-568-0941 Patient willbe directive testo scree on sppointment Foxrequstion ore dieclyt0 boos» MRAY ln (No Appointments) c+ nchdag hospital and Fs, Progiamigiste htp//wenhealth gouca/en/publie/prograns/h faites aspxGNMI MISSISSAUGA GNMis ascent free environment MRI | CT| ULTRASOUND | XRAY wwwgnmica info@gamica Wir tude) ARRIVE ATLEAST 30 MINUTES BEFORE YOUR APPOINTMENT UNLESS OTHERWISE SPECIFIED. LATE APPOINTMENTS MAY BE REBOOKED. FOR PATIENTS WITH KNOWN ALLERGIES AND CLAUSTROPHOBIA Ftv patenthas know contract ery he requesting physconirezpnebiefrorgsnzrg he premedication riovtothe patients scan Contac lrg premedication Prdhizone Sng PO.13hour and haw pre-exminaton ais BenarySomgP2. | hor pre-exsninstion. FFevepatenthascaurtrophabs he requesting physica re for orgonzingthesedaton, NOTE: Benacyandoralzeaton can cause drowsiness Patients souldmake sangeet tobe driven rom the exsmintion ITIS CRITICAL FOR PATIENT SAFETY THAT ALL RELEVANT SECTIONS ON THE FRONT OF THE REQUISITION ARE COMPLETED BY THE REFERRING PHYSICIAN. INCOMPLETE REQUISITIONS WILL BE SENT BACK FOR COMPLETION. Pe hana ue eo ne nd ARRIVE 15 MINUTES EARLY TO REGISTER, ‘ABDOMEN No eating or drinking (smoking or chewing gum) 4 hours prior to the appoint nent. ‘ABDOMEN /PELVIS No eating 4 hours prior to the appointment. START drinking 5 cups of water (40 oz oF 125 litres) 2hours before your examination FINISH drinking at least thour prior to your examination DO NOT empty your bladder before your examination, Note: I your bladder isnot full YOUR APPOINTMENT MAY HAVE TO BE RESCHEDULED OBSTETRICAL/PELVIS Aullbladerisnecessary fora thorough examination af the pelvis and pregnant uterus. START crinkingS cups of water (40 o2. or 25 litres) or other fluid 2hours before your examination. FINISH drinking at least 1 hour prior to your examination DO NOT empty your bladder before your examination, Note: f your bladder is not full YOUR APPOINTMENT MAY HAVE TO BE RESCHEDULED PROSTATE (TRANSRECTAL) FLEETENEMA 2 hours before examination {kit ay be purchased at yaur pharmacy) Drink 34 02. oF 1 Litre of water Thaur priate appointment Donot go tothe washroom. ESSN ne nr) CUNT) MISSISSAUGA DIRECTIONS FROM TORONTO ‘AIAX DIRECTIONS FROM TORONTO The Emerald Centre aow HanwoodPlaca 1oKingsbridge Garden Circle Ext Hwy 403(QEWanitor) 300 Harwood Ave South ese Phone: 905-568-3768, NorthonFurontareSt Phone: 905-426-8976 sts Bye Fax 905-568-0941 Left onkingsbrge Caréenc Fax poe4e-5234 Let med CT | MRI | ULTRASOUND | xR eR en Tucan cr La Uestesbesid orton PARKING Letintocivenay FREE PARKING