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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