ONLINE REFERRAL FORM

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Patient Information

Patient Last Name *

Patient First Name *

Home Phone

Cell Phone *

Email *

Confirm Email

OHIP Number

Version Code

Sex

Male
Female

Date of Birth

Additional Information

WSIB / Non-OHIP Third Party

WSIB
Non-OHIP Third Party

Claim Number

Injury Date

Company Name

Company Phone

Is patient able to come on short notice?

Patient consents to appointment information being disclosed in a telephone / sms / email message?

Physician Information

Referring Physician Last Name

Referring Physician First Name

Office Phone *

Office Fax

Email *

Confirm Email

Billing Number

Referring Date

Exam Requested

MRI
CT
Ultrasound
Bone Density (BMD)
Breast Imaging
X-Ray
Nuclear Cardiology (Myocardial Perfusion)
Cardiology
Nuclear Medicine
Non OHIP Screening Studies

MRI

Please complete with patient.

Clinical History - Exam Requested

History of Kidney Disease?

Creatine Levels Within Last 6 Months *

Date of Creatine Levels

GFR Levels Within Last 6 Months *

Date of GFR Levels

Allergy to gadolinium contrast?

Allergy to gadolinium contrast specification

Have you ever had a previous MRI?

Previous Relevant Exams (Please Bring to Appointment)

Previous Surgeries

Has metal ever gone in your eye?

Please perform orbital x-ray and upload reports

Drag & Drop Files, Choose Files to Upload

Are you on dialysis?

Are you claustrophobic?

Do you have any of the following:

Aneurysm Clips
Artificial Cardiac Valve
Cardiac Pacemaker
Cochlear Implants
Coil / Stents
Neurostimulator
Retained Pacing Wires
Shrapnel / Bullets
Other

Checkboxes *

Patients with a cardiac pacemaker or implanted cardiac device must be referred to a hospital for imaging

Other Implanted Device Description

Please specify date, type, implant model

CT

Clinical History - Exam Requested

History of Kidney Disease?

Creatine Levels Within Last 6 Months *

Date of Creatine Levels

GFR Levels Within Last 6 Months *

Date of GFR Levels

Last Menstrual Cycle

Known Allergies

Previous Relevant Exams (Please Bring to Appointment)

Previous Surgeries

Previous Reaction to IV Contrast?

Describe Reaction to IV Contrast

Ultrasound

Clinical History - Exam Requested

Select all that apply

On Desktop: Hold Ctrl (Windows) or ⌘ (Mac) to select multiple.

General

Abdomen
Renal
HCC Surveillance / Portal HTN
Bladder
PVR - Post Void Residual
AAA Screening
Abdominal Wall / Hernia
Inguinal Canal
Scrotum
Thyroid
Neck

Female Pelvis

Pelvis - Transvaginal
Pelvis - Transabdominal

Male Pelvis

Pelvis - Transrectal
Pelvis - Transabdominal Bladder & Prostate

Musculoskeletal

Shoulder
Elbow
Wrist
Hand
Hip
Knee
Achilles Tendon
Ankle
Foot
Plantar Fascia
Lumps & Bumps
Other

Shoulder Laterality

Bilateral
Left
Right

Elbow Laterality

Bilateral
Left
Right

Wrist Laterality

Bilateral
Left
Right

Hand Laterality

Bilateral
Left
Right

Hip Laterality

Bilateral
Left
Right

Knee Laterality

Bilateral
Left
Right

Achilles Tendon Laterality

Bilateral
Left
Right

Ankle Laterality

Bilateral
Left
Right

Foot Laterality

Bilateral
Left
Right

Plantar Fascia Laterality

Bilateral
Left
Right

Lumps & Bumps Description

Other Musculoskeletal Description

Vascular Lab

Peripheral Arterial Legs - ABI
Peripheral Arterial Arms
Carotid Arteries
Aorta
Portal Venous Hypertension
Venous Insufficiency / Varicose Vein Assessment
Peripheral Venous Legs - DVT
Peripheral Venous Arms - DVT
Other

Peripheral Venous Legs - DVT Laterality

Bilateral
Left
Right

Peripheral Venous Arms - DVT Laterality

Bilateral
Left
Right

Other Vascular Lab Description

Obstetrics

OB - Under 16 Weeks
OB - 18 to 20 Weeks
OB - Fetal Growth
OB - High Risk
Biophysical Profile (BPP)
EFTS - Nuchal Translucency (11 - 14 Weeks)

LMP Date

Other Ultrasound Description

Bone Density (BMD)

Clinical History - Exam Requested

BMD Description

Baseline
3 Year - First Follow Up
Low Risk: 5 Year
High Risk: 1 Year

Breast Imaging

Clinical History - Exam Requested

Breast Ultrasound Laterality

Bilateral
Left
Right

Mammography

OBSP
Screening Mammogram
Diagnostic Mammogram

Diagnostic Mammogram Laterality

Bilateral
Left
Right

X-Ray

No appointment required. All locations are walk-in during business hours.

Clinical History - Exam Requested

Select all that apply

On Desktop: Hold Ctrl (Windows) or ⌘ (Mac) to select multiple.

Chest

Chest PA & LAT
Ribs (Includes PA Chest)
Sterno - Clavicular
Sternum

Ribs (Includes PA Chest)

Bilateral
Left
Right

Head & Neck

Soft Tissue
Skull
Sinuses (Uninsured)
Facial Bones
Nose
Mandible
Orbits
TM Joints

Spine & Pelvic

Cervical Spine
Thoracic Spine
Lumbar Spine
Pelvis
S.I. Joints
Sacrum / Coccyx
Scoliosis

Abdomen

ABD Series
KUB (Single View)

Upper Extremities

Hand
Wrist
Elbow
Shoulder
Forearm
Humerus
Clavicle
A.C. Joints
Scapula
Finger

Hand Laterality

Bilateral
Left
Right

Wrist Laterality

Bilateral
Left
Right

Elbow Laterality

Bilateral
Left
Right

Shoulder Laterality

Bilateral
Left
Right

Forearm Laterality

Bilateral
Left
Right

Humerus Laterality

Bilateral
Left
Right

Clavicle Laterality

Bilateral
Left
Right

A.C. Joints Laterality

Bilateral
Left
Right

Scapula Laterality

Bilateral
Left
Right

Finger Laterality

Bilateral
Left
Right

Left Finger Digit

Right Finger Digit

Lower Extremities

Knee
Ankle
Foot
Hip
Femur
Tib & Fib
Heel
Toe

Knee Laterality

Bilateral
Left
Right

Ankle Laterality

Bilateral
Left
Right

Foot Laterality

Bilateral
Left
Right

Hip Laterality

Bilateral
Left
Right

Femur Laterality

Bilateral
Left
Right

Tib & Fib Laterality

Bilateral
Left
Right

Allergy Are Upper

Heel Laterality

Bilateral
Left
Right

Toe Laterality

Bilateral
Left
Right

Left Toe Location

Right Toe Location

Other X-Ray Description

Nuclear Cardiology (Myocardial Perfusion)

Clinical History - Exam Requested

Nuclear Cardiology Description

Exercise
Persantine

Weight

In Kilograms

Height

In Inches

Cardiology

Clinical History - Exam Requested

Cardiology Description

Stress ECG (Exercise Stress Test)
Echocardiogram
Stress Echo
Holter Monitor
Ambulatory Blood Pressure Monitor ($60)

Holter Monitor Description

24 Hr
48 Hr
72 Hr

Nuclear Medicine

Clinical History - Exam Requested

Select all that apply

On Desktop: Hold Ctrl (Windows) or ⌘ (Mac) to select multiple.

Bone Scan Description

Whole Body
Specific Site
Include X-Ray

Specific Site Description

Gastrointestinal Description

Biliary Scan / HIDA Scan

Endocrine Description

Parathyroid Scan
Throid Scan

Thyroid Scan Description

Uptake & Scan
Scan Only
Uptake Only
Ultrasound

Non OHIP Screening Studies

Clinical History - Exam Requested

Non OHIP Screening Description

Whole Body MRI
DEXA Body Composition

Acknowledgement *

This examination is an elective screening procedure performed at the patient’s discretion, intended for general health assessment, and is not a substitute for medical advice, diagnostic evaluation, clinical assessment, or the management of known medical conditions or symptoms.

Physician Signature *

Clear Signature

Final Acknowledgement *

By submitting this form, I confirm that I am a healthcare provider making this patient referral. I consent to GNMI Medical Imaging collecting and using the information provided to process this referral and to communicate regarding the patient’s care. I understand that this information will be handled securely and in accordance with GNMI Medical Imaging’s Privacy Policy. Submission of false, fraudulent, or unauthorized information may result in the matter being reported to appropriate authorities, including law enforcement.

ONLINE REFERRAL FORM

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Patient Information

Additional Information

Physician Information

MRI

CT

Ultrasound

Bone Density (BMD)

Breast Imaging

X-Ray

Nuclear Cardiology (Myocardial Perfusion)

Cardiology

Nuclear Medicine

Non OHIP Screening Studies