Download Image Guided Interventional Procedures Request

Patient label here or information below is required
Last Name
First Name
Image Guided Interventional
Procedures Request
Gender o Male
o Female
Address (street, city, province, postal code)
Birthdate (yyyy-Mon-dd)
< Fax to Diagnostic Imaging; fax numbers listed at
http://www.albertahealthservices.ca/diagnosticimaging
PHN
< Urgent/Emergent requests must be Preferred Facility
discussed by direct consultation with
the radiologist
Daytime Phone
Inpatient location
Referring Physician (PRINT first and last name)
Physician Phone (required)
Signature
Copy to Physician (first and last) Copy to Fax
Date (yyyy-Mon-dd)
Physician Fax (required)
Exam requested (indicate specimen required for biopsies/drainages)
Relevant clinical history/presumptive diagnosis
Clinical question to be answered
Relevant Previous Imaging Studies
Location
Type
Current Patient Condition
Date of LMP (yyyy-Mon-dd)
Date (yyyy-Mon-dd)
o cm
Height
o in
Attached copy
o No
o Yes
o kg
Weight
o lbs
Condition
No Yes If Yes:
Allergies (include any reaction to contrast media) o o Specify:
On Anticoagulants
o o Specify:
Medications (including ASA, Plavix)
o o Specify:
Isolation Precautions
o o Specify type:
Diabetic
o o Metformin (Glucophage) o No
o Yes
Renal Insufficiency
o o
o o Run days:
On Dialysis
o o
Mechanical lift/transfer required
For biopsies and drainages, indicate specific lab or specimen required: (attach orders)
o Creatinine
o Glucose
o LDH
o Albumin
o Bilirubin
o Gram Stain
o AFB
o Fungi
o Culture & Sensitivity (specify antibiotic use):
o pH
o Cytology
o Cell Count
o Other (specify):
Radiologist to Complete o CT
o IR Suite
o US
Pre-Care
Admit ____ hrs prior
Priority
o Day Med
Bloodwork
o None
o Pre-Op required
o 24 hr
o Admit day of exam;
o DIRR
o Electrolytes o LFT’s
Admit ____ hrs prior
o 1 week
o Next Available
o Other (specify):
o OP Radiology
o GA
o PAC
o Inpatient
o Creatinine
o CBC
o Bilirubin
o PT/INR
o Other (specify):
Required within
o 1 week
o 4 weeks
prep required
o Admit day of exam and GA;
Admit ____ hrs prior
prep required
Length of Recovery
o N/A o 2 hrs o 4 hrs o ___ hrs
Procedural Protocol
Patient position
o supine
o prone
Department Use Only Date format: yyyy-Mon-dd - Time format: hh:mm
Date Received
Time Received
Appointment Date
Appointment Time
More info required o No
o Yes
09015(Rev2017-03)
o Yes (specify):
Day Med booked o No