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Sjhc-form-template-sept-25-2009.doc

Name: ____________________________________ Male … Female … CT (CONTRAST AND NON-CONTRAST),
MRN :_____________________________________ INTERVENTIONAL, AND BIOPSY
DOB: _____________________________________ Address:___________________________________ __________________________________________ Telephone: _________________________________ OHIP #: ____________________________________ INCOMPLETE FORMS WILL BE RETURNED AND NOT PROCESSED
EXAMINATION(S) REQUESTED † STAT/TODAY (Call CT or Vascular Radiologist) † URGENT † ROUTINE
WSIB/Third Party Claim Number:
CLINICAL HISTORY Isolation Precautions: † N/A † Contact † Droplet † Airborne † Reverse

Allergy to Intravenous Contrast: † NO † YES (If yes, contact DI for pre-medication)

CT SCAN (Contrast Enhanced Only) and INTERVENTIONAL PROCEDURES REQUIRING IV CONTRAST
Estimated Glomerular Filtration Rate (eGFR) in mL/min:
For all patients greater than 60 years of age or those at risk for underlying renal and severe liver disease, diabetes, hypertension,
solitary kidney, and/or previous organ transplant, complete the following:
IV Contrast Preferred † YES † NO eGFR:
If eGFR is less than 45: † CIN Protocol Started † CIN Protocol Declined Time Started: Time Ready to Scan: If eGFR is not available, complete the following (required for eGFR calculation):
Creatinine (umol/L)
years Gender: † M † F † Ethnicity: Black For all patients taking Metformin
† Patient has been informed to discontinue Metformin for 48 hours following injection of IV contrast.
† Patient has also been informed that a blood test is required after 48 hours to determine whether he/she can resume Metformin.
INTERVENTIONAL/BIOPSY (excluding Breast, Thyroid, Prostate and Superficial Biopsies)
CBC, INR, and PTT within the last 28 days required
Results on Sunrise † YES † NO Outside Lab (Name):
Ordering Physician: Advise patient of (or write order for) the following instructions (SEE PAGE 2/BACK OF THIS PAGE)

ADDITIONAL INFORMATION
REQUESTING PHYSICIAN
† Falls Risk † Lifting Device Required † Patient with Restraints (must be accompanied) Does Patient Consent to Appointment Information Being Disclosed in a Is Patient Able to Come in on Short Notice? † Yes † No Contact Telephone Number (if different from above): DATE/TIME
SIGNATURE
PRINT NAME

DD / Month / YYYY

__ __:__ __h
(DO NOT FAX/SEND THIS PAGE TO DIAGNOSTIC IMAGING)
INTERVENTIONAL AND BIOPSY
(EXCLUDING BREAST, THYROID, PROSTATE, AND SUPERFICIAL BIOPSIES)
Instructions for Ordering Physicians


Advise patient of (or write order for) the following instructions
(if contraindicated, notify Radiologist):

• Acetylsalicylic Acid (Aspirin ®) – Stop taking 5 days before renal biopsy, biliary intervention, and • Clopidogrel (Plavix ®) – Stop taking 5 days before • Pentoxifylline (Trental ®) – Stop taking 5 days before • Coumadin (Warfarin ®) – Stop taking 5 days before (excluding breast biopsy) • Low Molecular Weight Heparin – Stop taking 24 hours before • Heparin – Stop taking 4 hours before

Source: http://www.stjoe.on.ca/programs/pdf/ct_form.pdf

mta.uwinnipeg.ca

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