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mri & Ct403.777.4MRI (4674)

120 Mayfair Place 6707 Elbow Dr. SW Calgary, Alberta T2V 0E3

Phone: 403.777.4MRI (4674) Bookings: 403.301.4525 Fax: 403.777.3198

Toll Free: 1.866.777.7570 Toll Free Fax: 1.877.777.3199 www.mayfairdiagnostics.com

Wholly owned by:

Patient information

Name: _______________________________________________________ Date of Birth: __________________________________________________ Home: _______________________________________________________ Work: ________________________________________________________ Cell: _________________________________________________________ WCB Claim Number: _____________________________________________

Date: _________________________________________________________ Address: _______________________________________________________ City: __________________________________________________________ Province: ______________________________________________________ Postal Code: ____________________________________________________ Insurance: _____________________________________________________

exam tyPe

mri

Ct

Patient History Area to be examined:

List previous exams. Please submit images and reports.

History and presumptive diagnosis:

£ Hearing Aid £ Claustrophobia £ Pregnant (LMP £ Over 395 lbs.

)

£ Cardiac pacemaker £ Coronary artery, heart valve surgery £ Aneurysm surgery or clip £ Inner ear implant

£ Gunshot, metal fragment £ Welder, machinist, sheet metal worker1 £ Eye/head metal foreign body1

1

Forward current orbit radiograph report.

Ct HealtH assessment exams

(Health assessment scans are not recommended routinely for patients under 40 years of age.)

Ct focused Health scans £ Heart (Coronary Calcium Score) £ Lung (Lung Cancer Survey) £ Osteoporosis Scan (Bone Densitometry)

£ Vi

rtua

l C o l o n o s c o p y 2 ( C o l o n C a n c e r S u r v e y )

Ct Health assessment Packages £ Mayfair INFORM (Heart + Lung + Osteoporosis Scan) £ Mayfair ASSURANCE (INFORM + Virtual Colonoscopy) £ Mayfair PREMIER (INFORM + Abdomen/Pelvis (Contrast-Infused CT))3 £ M a y f a i r C O M P R E H E N 3 (PREMIER + Virtual Colonoscopy) S I V E

2

Recent serum creatinine recommended: __________________

3

Contrast-infused CT imaging requires clinical indication and recent serum creatinine:

____________

HealtHCare Provider’s information

Ref. Health Provider: Signature: ____________________________________________________ Phone: _______________________________________________________ Fax: _________________________________________________________ Copy to: ______________________________________________________ Stat Report

_________________________________

£

Address: ________________________________________________________ ______________________________________________________________ Practitioner's ID/Stamp: ____________________________________________ ______________________________________________________________ ______________________________________________________________

radiologist’s ProtoCol

teCHnologist’s notes

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