Imaging referral forms


Breast Assessment Imaging

Breast Assessment Imaging requisition

Computed Tomography (CT)

CT requisition (fillable file)
CT Inpatient Preparation sheet 
CT Outpatient Preparation sheet
CT Outpatient Information
Medical History for Procedure Form: CT Lung Biopsy
Patient Education pamphlet: CT Lung Biopsy 

General Radiology Fluoroscopy 

Imaging requisition
General Radiology Fluoroscopy Inpatient Preparation sheet  
General Radiology Fluoroscopy Outpatient Preparation sheet
Medical History Form for Lumber Punctures and CT Myelograms

Interventional Radiology

Note: Each referral require the following: part A of the Consent for Special Radiological Procedures, completed IR Consultation Requisition and completed IR Medical History Form for interventional radiology procedure. 

Consultation Requisition (IVR Requisition)
Consent Form
Medical History Form (MHF)
Hospital Registration Form (HRF)
IVR Guidelines for Bleeding Risks
Interventional Radiology Inpatient Preparation sheet
Interventional Radiology Outpatient Preparation sheet
Process for an IVR consultation and procedure for non-KHSC patients

Magnetic Resonance Imaging (MRI)

MRI requisition and screening form
MRI Patient Preparation sheet
HRF History and Physical KHSC
Pediatric Pre Surgical Screening Assessment
Adult Pre Surgical Screening Assessment

Nuclear Medicine

Imaging requisition
Nuclear Medicine Inpatient/Outpatient Preparation Sheet


Imaging requisition
Obstetrical Requisition to the Ultrasound
Ultrasound Inpatient Preparation sheet
Ultrasound Outpatient Preparation sheet
Vascular Ultrasound Lab Requisition