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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