LAST NAME FIRST NAME PERSONAL HEALTH NUMBER ADDRESS DATE OF BIRTH PRIMARY PHONE ALTERNATE PHONE HEIGHT (CM) Ht checked WEIGHT (KG) Wt checked EXAM REQUESTED (Appropriateness checklist must accompany referrals for lumbar spine, knee, hip, shoulder) ▲ ▼ REASON FOR EXAM / RELEVANT CLINICAL HISTORY (include any relevant medications) ▲ ▼ See CHECKLIST items on page 2. Safety Screen All No Patient pregnant   No   Yes Internal Electrodes or Wires   No   Yes Neurostimulator   No   Yes Metallic Orbital Foreign Body   No   Yes Implanted Infusion Pump   No   Yes Shrapnel and/or Bullet   No   Yes where: Cerebral Aneurysm Clip   No   Yes, type: Middle Ear Prosthesis   No   Yes, type: Intravascular Stent/Filter   No   Yes, type: Breast Tissue Expander   No   Yes (not breast implants) type: Patient claustrophobic   No   Yes, prescribe sedation Cardiac
Pacemaker/Defibrillator   No   Yes, type: ? Days since last eGFR.
Consider recheck if > 90d. REQUESTING CLINICAN NAME MSP BILLING NUMBER CLINICIAN PHONE CLINICIAN FAX