Patient Information
Surname:
First Name:
DOB: 1960-01-01
Gender: Female
Address (Line 1):
City:
Province:
Postal Code:
Exam(s) Requested CT RequisitionandMRI Requisition
Triage Considerations
Requested Triage Priority Routine
CT Exam/Region(s) of Interest:Neck Neck,Specific area of interest
Neck angiographyandSoft Tissue Neck,Spine Spine,Specific area of interest
Cervical Spine
CT Request: Clinical History / Indication

Motor vehicle accident
MRI Exam/Region(s) of Interest:Neck Neck
Specific area of interest
Neck angiographyandBrachial plexus
Brachial Plexus: Bilateral
MRI Request: Clinical History / Indication

Motor vehicle accident
MRI Safety Screening
None of the above None of the above

Patient Safety Screening

Select where applicable

Renal Assessment Questions: No known kidney issues
Known hypersensitivity to contrast agents: Unknown
Currently breastfeeding Currently breastfeeding
Patient Weight and Height
Units: Metric (cm/kgs)
Metric height and weight required
Weight (kgs): 73
Height (cm): 164
Date of Weight/Height: 2026-08-30
Scheduling
Request specific appointment date or time interval based on: Clinical Reasons
Specify Timeframe:
Clinical Reasons: Patient navigation (eg., Before a specialist appointment)
Preferred Consultant or Location
Patient willing to travel for shorter wait time Patient willing to travel for shorter wait time
Referrer's Information
Address (Line 1):
City:
Province:
Postal Code:
Signed: Dr. Bones
Role: Family Physician
referralService