Outpatient Radiology Patient Information: Appt: Date: Referring Doctor: Copy To: Billable To: MSP ICBC WCB Other: Exam: Clinical Information: Patient Instructions:


WCMI: Royal City Centre #200 - 610 Sixth St. New Westminster Phone 604-522-6818 Fax 604-522-6810 UX M-F 8:00-4:30 U only Sa 9:00-2:00 WCMI: Sapperton #401 - 233 Nelson’s Crescent New Westminster Phone 604-526-2466 Fax 604-521-5904 X only M-F 7:45-2:45 WCMI: Austin Ave. #101 - 1015 Austin Ave. Coquitlam Phone 604-937-5588 Fax 604-936-8800 UX M-F 8:00-4:30 U only Sa 9:00-2:00 WCMI: City Centre One #1 - 13737 - 96th Ave. Surrey Phone 604-581-4616 Fax 604-582-9022 X M-F 8:00-4:30 WCMI: Guildford #3 - 15300 - 105th Ave. Surrey (Guildford Health Centre) Phone 604-581-1101 Fax 604-582-8520 UX M-F 8:00-4:30 U only Sa 9:00-2:00 WCMI: Delta/Scott Rd #105 - 8318 - 120th St. Delta Phone 604-590-2211 Fax 604-581-0405 UX M-F 8:00-4:30; U only Sa 8:00-4:30 M M-F 9:00-4:00 Brooke: Metrotown #100 - 4980 Kingsway Burnaby Phone 604-434-1345 Fax 604-435-1309 UXMB M-F 8:00-5:00 Brooke: North Burnaby #20 - 4218 East Hastings St. Burnaby Phone 604-299-2666 Fax 604-299-5773 UX M-F 8:30-5:00 (website) #100 - 3001 Gordon Ave. Coquitlam Phone 604-941-7611 Fax 604-942-4612 UX-MRI M-F 8:00-4:30 Evenings and Sa closed VMI: Langley #200 - 5503 - 206th St. Langley Phone 604-534-4114 Fax 604-534-7877 UXM M-F 8:00-5:00 VMI: Chilliwack 45731 Patten Ave. Chilliwack Phone 604-795-7205 Fax 604-795-3543 X only M-F 8:30-4:30, closed Tu VMI: Abbotsford/Clearbrook #102 - 32475 Simon Ave. Abbotsford-Clearbrook Phone 604-855-0112 Fax 604-855-0109 UX M-F 8:00-5:00
Subject:

TYPE OF PROCEDURES:

OBSTETRICS:
LMP: EDC:
First Trimester Dating OBS US
Antepartum bleeding OBS US
Detailed 18 week OBS US

MODALITY:
X-ray Ultrasound
Barium Enema ES&D

SIDE:
Left Right Bilateral

BODY PART:
Head Sinuses
Chest Abdomen Pelvis
C-spine T-spine L-spine
Shoulder Shoulder FOI
Humerus Elbow Forearm
Wrist Scaphoid Hand Finger
Hip Hip THA Femur
Knee Knee TKA Knee OA
Lower leg Ankle Foot
Ankle OA Foot OA

PATIENT INSTRUCTIONS:
Patient to book
X-ray:
UGI, esophagus, small bowel
Ba enema
Hysterosalpingogram
Ultrasound:
US Abdomen
US Abdomen and Pelvis
US Renal
US Pelvis or Obstetric
Mammogram:
Mammogram
BMD:
Bone Mineral Density

  F5 to reopen
U = Ultrasound
X = X-ray
M = Mammography
F = Fluoroscopy
B = BMD
H = Hysterosalpingogram