Reverse Side
Wt check >3m ago
cm
kg
▲
▼
Additional copy to:
Stamp
Signature
Subject:
Choose Tickler reminder date
4 wks
6 wks
IHA MRI Imaging eForm, V3_May20_2022, by Dr. John Yap, is licensed under a
GPL
. Based on FHA Imaging Req by Drs. Page et al.
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Choose a location
Cranbrook
Kelowna
Trail
Penticton
Kamloops
Vernon
CAR GUIDELINES
SIDE:
Left
Right
Bilateral
BODY PART:
Head
IAC
Sinuses
Carotids
Thyroid
Chest
Breast
Abdomen
Pelvis
Renal
C-spine
T-spine
L-spine
Shoulder
Humerus
Elbow
Wrist
Forearm
Scaphoid
Hand
Hip
Femur
Knee
Ankle
Foot
Lower leg
Change contact info as needed
Name:
Office Ph:
Office Fax:
Call if positive
Call result
Fax if positive
Fax
Send to ER if positive
URGENT
EMERGENT
Renal Function
Creatinine:
eGFR:
eGFR more than 90 days old