Diagnostic imaging referrals

Breast Assessment Imaging

• Breast Assessment Imaging requisition

Computed Tomography (CT)

• CT requisition (fillable file)
  • Medical History for Procedure Form: CT Lung Biopsy
• Ontario Lung Screening Program referral  

General Radiology Fluoroscopy 

• Imaging requisition
  • 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 

Magnetic Resonance Imaging (MRI)

• MRI requisition and screening form
  • HRF History and Physical KHSC

Nuclear Medicine

• Imaging requisition
  • Nuclear Medicine Inpatient/Outpatient Preparation Sheet

Ultrasound

• Imaging requisition
• Obstetrical Requisition to the Ultrasound
• Vascular Ultrasound Lab Requisition

Office contact information 

KHSC's Hotel Dieu Hospital site
166 Brock Street
Kingston, ON 
Ph: 613-544-3400 ext. 23020 
Fax: 613-544-6505 

KHSC's Kingston General Hospital site
76 Stuart Street 
Kingston, ON  
Ph: 613-548-2301 
Fax: 613-548-2413 

Queen's University Department of Diagnostic Radiology