IMPEXXUS MEDICAL IMAGING

Requisition Form
* indicates required field.
Patien information
OHIP # * V.C . *
Patient Name *
D.O.B *
M F
ULTRASOUND (By Appointment)
R L
THYROID & NECK
OBSTETRICS
MUSCULOSKELETAL ULTRASOUND (By Appointment)
R L
Finger 1 2 3 4 5
R L
R L
Toe 1 2 3 4 5
BREAST IMAGING
R L
(Include Axilla)
Please indicate lump, pain
or discharge location
CARDIAC AND VASCULAR
R L Upper Lower
BONE MINERAL DENSITY
X-Ray (Walk-in)
ABDOMEN
CHEST
R L
HEADL
UPPER EXTREMITIES
R L
Digits 1 2 3 4 5
SPINE & PELVIS
SKELETAL SURVEY
LOWER EXTREMITIES
R L
Toes 1 2 3 4 5
Gastrics* (By Appointment)

(24 hours cancellation notice required, or a $50 fee will be charged)
Print Dr. Name *
Provider Number *