s NI AGAR A H EALTH SYSTEMENext available appointment at any NHS CT SitePLEASE FAX TO LOCATION NEAREST PATIENT'S RESIDENCE

Or Choose: trcNc 905-378-4647 Fax 905-358-7438trSCG 905-378-4647 Fax905-684-6990dWHS 905-378-4647 Fax905-732-9537

INCOMPLETE FEOI,JISITIONS WILL BE RETURNED

CT ConsultationPlease PFIINT patient infomation below.

RequisitionPlease do not imprint.

il

T

Sufiame First Name E ouDaiient

E lnpalient site

-

FllRm

-EEn sit"-E Relerral siie

-

FllRm

D.O_8. Sex H.C.N.

Relerring Physician Physicians to receive copies of report

City Seterring PhysicianPhone (home) Name

sIB

Claim # Dale of Accident dd/mm/yy Address

Employer when accident happened s.t.N. city Postaloode

Employer's Address

AllergyHislory

Head Chest Abdomen / Pelvis RetroDeritoneum OtherE Routine E Routine E Liver E Adrenals E Extremity lsrerlly a'e:;

E Sinus E High Resolution E Pancreas E Kidneys ESpine -.r';' t

E Orbits E Pulmonary Embolus E Spleen tr E Bony Pelvis

tr tr EAorta tr E Neck

tr tr DRenal Colic tr n

BELEVANT PBEVIOIIS IMAGING STUDIES MUST

Historv and Findinqs - include previous imaqinq and laboratory studies Renal History

Physician's Signature:

Urgent Result Contact Number:

Does your patient have any history of renalimpairment or dialysis treatment? EYes ENoDoes your patient have any history of hypenension,or vascular disease? trYes trNo

Does your patient have diabetes? trYes trNo

lf yes are they on Metformin? trYes trNoDoes your patient have anyfamily history of renal disease? trYes trNo

Yqur patient may require contrast media duringthis study, it ihe answer is "Yes" to any ol theabove, or your patient is older than 70 yrs.,please provide a creatinine level performedwithin the last 2 months.

Creatinine- pmol/L or GFB

-WTIS Clinical lndicalion tor Scan Radioloqist Protocol Date Requisition Received

tr Cancer Staging / Diagnosistr Other

2 3 4 D E (office use only)

l N.:

Date Notilied

r.l

Appointment: DayI I Month[ ] Year[ ] Time: HRS WHS tr GNG D SCG tr86 Bev. 1212011

Canadian CT Head Rule Has to be completed for all non contrast Head CT

[ ] Not a trauma

[ ] GCS <13

[ ] Age <16

[ ] Anticoagulants or Bleeding D/O [ ] Open Skull #

[ ] GCS <15 2hrs post injury [ ] Suspected Open or Depressed Skull # [ ] Any sign of Basal Skull # [ ] Age 65yr or older [ ] Vomiting 2 or more times [ ] Amnesia 30min before impact [ ] Dangerous Mechanism (Pedestrian vs car, MVA with ejection, Fall 3ft or more)1.

CCT

HR E

xclu

sion

Crit

eria

2. A

ny E

xclu

sion

s M

et?

3. W

as C

CTHR

Met

?

Allergy History

Must Complete CCTH Rule above if ordered

Temporary McMaster-NHS CT Head Rule Study SCS Only

Proceed to exclusion

NOYE

S

[ ] YES (CT head recommend)

[ ] NO (CT head not recommend)

Important Note: This req is part of a NHS & McMaster NRC Study. The CT head will be performed if ordered regardless of the CT Head Rule. Clinical judgment is paramount.

[ ] Excluded from Rule