Information on this form is protected under the Health Information Act (HIA), Alberta. It is collected solely for the purpose of diagnostic imaging and is handled in accordance with HIA custodian obligations.
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Patient Information
Clinical History
Area(s) to be imaged and detailed clinical history. Please be as specific as possible and include relevant reports.
3T MRI — Wide Bore
Select Exam(s)
MRI Contraindications (check all that apply)
CT Scan — Wide Bore
Select Exam(s)
CT Safety — Please Complete
Known allergy to contrast?
Other allergies?
Renal function (<90 days)?
GFR:
Dialysis?
Pregnant?
LMP:
⬡ Health Assessment Programs — Private Pay
MRI Screening
CT Screening
Genetic Screening Add-On
Referrer Information
Report Options
⚠ This requisition is valid for 12 months from the date of request. Please attach relevant imaging reports where applicable. For urgent bookings, call directly.