Patient Name:
DOB:
Sex:
HIN#:
Phone:
Address:
Weight:
CPSID #:
Billing #:
Referral Date:
Physician Address/Phone/Fax:
CC:
Generic Diagnostic Imaging Requisition: This requisition form can be taken to any licensed facility providing healthcare services, including independent healthcare facilities (IHFs) and hospitals, such as those listed on the IHF Program website.