Pediatric Diagnostic Imaging
Requisition
403•541•1200
PATIENT INFORMATION
ULTRASOUND • check all that apply
Date of Issue:
Patient Name:
Parent or Guardian Name:
Birthdate: Day
Gender: Male
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Month
Female
Year
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Address:
City/Province:
Postal Code: Home: Cell: AHC#: Date and time of appointment: RELEVANT HISTORY
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Abdomen
Pelvis
Renal (Kidneys / Bladder)
Bilateral Hips (under 6 months)
Cranial (Fontanelle must be open)
Thyroid
Spine (under 4 months)
Neck
Scrotum /Testicles
Pylorus
Inguinal
❒ Left ❒ Right
Other: REFERRING PHYSICIAN
Physician Name: Signature: Phone: Fax: Additional report to: Call emergency report to: Address: PROCEDURE REQUEST
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CD Copy
PHYSICIAN STAMP
Please see reverse for patient instructions
Pre-Procedure Instructions
PLEASE REMEMBER
Bring this requisition with you.
Bring your current Alberta Health Care Card.
Phone if you are unable to keep a scheduled appointment.
Patients suspecting pregnancy should consult their physician prior to any examination.
ULTRASOUND
An appointment is required for ALL ultrasound exams.
ABDOMINAL EXAM
(INCLUDES KIDNEYS, LIVER, BILE DUCTS, GALLBLADDER, SPLEEN, PANCREAS, ABDOMINAL VESSELS)
0-36 Months – Do not eat three hours prior to exam time.
3 Years and older – Do not eat for six hours prior to exam time. Clear fluids are allowed – no milk or cream.
PELVIC/RENAL EXAM
(INCLUDES KIDNEYS AND URINARY BLADDER. ALSO INCLUDES UTERUS AND OVARIES FOR FEMALE PATIENTS)
0-36 Months – No preparation is required. Be prepared to spend some time at the clinic, as the sonographer
may have to wait until the bladder fills.
3-10 Years – Full bladder is required. Empty bladder one hour prior to the exam, then drink two eight ounce
glasses (500 ml) of water. Do not empty bladder until the exam is completed.
10 Years and older – Full bladder is required. Empty bladder one hour prior to exam, then drink three eight
ounce glasses (750ml) of water. Do not empty bladder until the exam is completed.
COMBINED EXAM (ABDOMEN AND PELVIS)
(INCLUDES KIDNEYS, LIVER, BILE DUCTS, GALLBLADDER, SPLEEN, PANCREAS, ABDOMINAL VESSELS, URINARY
BLADDER; ALSO INCLUDES UTERUS AND OVARIES FOR FEMALE PATIENTS)
0-36 Months – Do not eat three hours prior to exam time. Be prepared to spend some time at the clinic, as the
sonographer may have to wait until the bladder fills.
3-10 Years – Do not eat for six hours prior to exam time. Full bladder is required. Empty bladder one hour prior
to the exam, then drink two eight ounce glasses (500 ml) of water. Do not empty bladder until the exam
is completed.
10 Years and older – Do not eat for six hours prior to exam time. Full bladder is required. Empty bladder one
hour prior to exam, then drink three eight ounce glasses (750 ml) of water. Do not empty bladder until the exam
is completed.
NECK, THYROID, SPINE, HIPS, CRANIAL & TESTICLES
Require no preparation.
PEDIATRIC PYLORUS
Nothing to eat or drink for 3 hours prior to your exam. Please bring a bottle of formula/breast milk or sterile
water which may be required during exam.
CLINIC LOCATIONS
ADVANCED MEDICAL IMAGING CENTRE
Suite 100, 2000 Veteran’s Place N.W., Calgary, AB T3B 4N2
FOOTHILLS PROFESSIONAL BUILDING
Suite 380, 1620 - 29th Street N.W., Calgary, AB T2N 4L7
AIRDRIE EFW RADIOLOGY CLINIC
Suite 204, 836 - 1st Avenue N.W., Airdrie, AB T4B 0V2
HIGH RIVER CLINIC
Suite 104, 303 - 9th Avenue S.W., High River, AB T1V 1B3
BEDDINGTON TOWNE CENTRE
Suite 200, 8120 Beddington Blvd. N.W., Calgary, AB T3K 2A8
SOUTHPORT ATRIUM
A8, 10333 Southport Road S.W., Calgary, AB T2W 3X6
Official Diagnostic
Imaging Provider
Phone: 403•541•1200 | www.efwrad.com | Fax: 403•210•8377