MRI REQUISITION

4401 University Drive, Lethbridge AB T1K 3M4
Toll Free: 1-844-425-5267
Fax: 403-328-1218 www.u3t.ca

PATIENTS WITH THE FOLLOWING DEVICES CANNOT RECEIVE AN MRI AT U3T MRI CENTRE:

Cardiac Pacemaker Defibrillator Cochlear Implant Neurostimulator

If you have any questions regarding these devices and MRI safety, please contact us at 1-844-425-5267.

Patients aged 8-17 are only eligible for an MRI if ordered by a physician who is licensed in Canada. U3T does not scan patients under the age of 8.

Preferred appointment date / time:

Office use only:

Exam code:

Name:
Address:		Postal Code:
City:		Province:
Phone #:

AHC #:		WCB#
Patient pay		Affiliate
Age:		DOB:
Male Female

Referring physician:
Clinic name:
Fax reports to #:

Send 2nd copy to:
Clinic name:
Fax reports to #:

PLEASE PROVIDE RELEVANT MEDICAL INFORMATION:

Are you claustrophobic?	Yes	No
Are you pregnant?	Yes	No	Last Menstrual Period:
Are you breastfeeding?	Yes	No	Last Menstrual Period:

Do you have a cardiac valve, stent, cerebral aneurysm clip/coil or any other implanted surgical device?
Yes No
If yes, please provide details:
Do you have a history that could result in a metallic foreign body in your eye (e.g., working with metal)?
Yes No
If yes, was it removed by a physician?
Yes No
If yes, location where performed:
Do you have normal kidney function?
Yes No

SPINE:

Cervical (Neck)
Thoracic (Upper back)
Lumbar (Lower back)
Sacroiliac Joints

JOINTS: Left Right

Ankle
Elbow
Foot
Hand
Hip
Knee
Shoulder
Wrist

HEAD:

Head:
Routine (Headaches etc.)
MS Screen (Head & Neck)
Trauma (Concussion etc.)
Internal Auditory Canal
(Hearing etc.)
Orbits (Vision etc.)
Pituitary
TMJ (Jaw joints)

BODY:

Abdomen
Abdomen & Pelvis
Chest Wall
Soft tissue masses (non-breast)
Aortic aneurysm screen
Pelvis
Prostate

COMPREHENSIVE SCAN:

Brain, Whole Spine, Abdomen, Pelvis
Brain, Whole Spine, Abdomen, Pelvis
(With Brain and Abdomen aneurysm screen)

OTHER:

By completing and remitting this form, you are providing U3T MRI Centre with your consent to review your relevant prior imaging and reports so that we can provide you with the highest level of patient care. If we cannot obtain your relevant medical history, we may request that you provide it to us. We are concerned for your privacy and your information will not be shared, sold, nor otherwise disclosed without your express written consent.

PREPARATION FOR MRI PROCEDURES:

Take medications as necessary.
Do not eat or drink for 4 hours before all abdominal studies – you may, however, take prescribed medications with a few sips of water.
Exams typically take 30 minutes.
Please discuss any allergies or medication requirements at time of booking.
Please inform the technologist if there is a possibility of pregnancy.
Unless otherwise specified, please arrive at least 30 minutes prior to your scheduled examination time. If you are late for your appointment, you may need to be rescheduled.
We require 24 hours notice to cancel or reschedule your appointment. “No shows” are subject to a $100 administration fee.
Be prepared to provide your license plate number upon check-in for parking validation.
Patients will be asked to change into provided garments for their scan. Please do not wear or bring jewelry or valuables to your appointment. U3T cannot be responsible for lost or stolen valuables.
Please note that children requiring supervision CANNOT be brought to your appointment.
Please inform us of any limited mobility prior to your examination – wheelchair assistance is available upon request.
We accept Debit, Visa, Mastercard and Cash ONLY – we do not accept personal cheques.

PRINT A BLANK FORM: PDF

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