Download For all appointments call: 306.477.1000

Mammography | X-Ray | Ultrasound
For all appointments call: 306.477.1000
Bring this requsition to your appointment at the following location:
SMI/ WOMEN’S IMAGING CENTRE
(X-RAY, ULTRASOUND &
MAMMOGRAPHY)
3 - 3110 8th STREET EAST
SASKATOON, SK S7H 0W2
TELEPHONE: 477.1000
FAX: 477.1071
UNIVERSITY HEIGHTS
(X-RAY ONLY)
110A-1804 MCORMAND DRIVE
SASKATOON, SK S7S 0A6
TELEPHONE: 956.3206
FAX: 956.3126
SPADINA
(X-RAY & ULTRASOUND)
10-750 SPADINA CRES. EAST
SASKATOON, SK S7K 3H3
TELEPHONE: 477-1000
FAX: 343-3648
LAKEWOOD
(X-RAY ONLY)
117 SLIMMON ROAD
SASKATOON, SK S7V 1J7
TELEPHONE: 382.5990
FAX: 382.5909
Exam Requested (please print legibly)
Pregnant?
Yes
No
LMP:
Clinical:
INDICA TE LOCAT ION OF ABNORMALITY
Doctor Signature:
Please complete if urgent
notification is required:
CC:
Fax Report:
R
L
Phone Report:
Patient Information
Appointment Date/Time:
Name:D.O.B (dd/mm/yy):
Address:SHSP:
MaleFemale
Home Phone: Work/Cell Phone:
Appointment preparation instructions on reverse side. Please call if you have questions.
Mammography | X-Ray | Ultrasound
Follow your exam instructions
Bring this requsition to your appointment
An appointment is required for all the following tests:
ULTRASOUND:
1) PELVIC OR BLADDER: 1 1/2 hours before your appointment, empty bladder and
drink four 8 oz. glasses of water immediately. Do not empty bladder until exam
is completed.
2) ABDOMINAL: Do not take anything to eat or drink for 8-10 hours prior to
examination (except medications with a small amount of water).
3) ABDOMINAL PLUS PELVIC: Fast for 8-10 hours but drink water as per the pelvic
ultrasound instructions. Do not empty bladder again until your exam is completed.
4) R
ENAL, THYROID, BREAST, SCROTAL, and SOFT TISSUE:
No preparation required.
5) PREGNANCY:
• Early (up to 10 weeks): 1 1/2 hours before your appointment, empty bladder
and drink four 8 oz. glasses of water. Do not empty bladder again until your
exam is completed.
• Mid (10-20 weeks): 1 hour before examination, empty bladder and drink
three 8 oz. glasses of water. Do not empty bladder again until your exam
is completed.
• Late (after 20 weeks): 1 hour before examination, empty bladder and
drink one 8 oz. glass of water. Do not empty bladder again until your exam
is completed.
MAMMOGRAPHY:
Avoiding caffeine for 3-4 days prior to your examination may significantly decrease
discomfort during the test. Do not use deodorant, talcum powder or glitter-containing
products on the day of examination.
APPOINTMENT POLICY
There are always patients waiting for appointments. If you need to cancel your appointment, please call as soon as possible so we can use the time for another patient.
For more information and directions to our clinics, please call our
office or visit our website: saskatoonmedicalimaging.ca