Request for Diagnostic Imaging

Patient Details:

Patient Name:

DOB:

Sex:

HIN#:

Phone:

Address:

Weight:

Examination Requested:

Historical/Clinical Findings/Other Relevant Info:

Requesting Physician:

CPSID #:

Billing #:

Referral Date:

Physician Address/Phone/Fax:

Copy To Physician (Name & Address):

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.