X-RAY, ULTRASOUND, Rolbev Medical Centre
Dr. Paul Morris MBBS CARDIAC TESTING & EEG 1 Fernleigh Avenue, May Pen
Phone:876-986-2311
Form
PATIENT INFORMATION APPOINTMENT DATE/TIME
LAST NAME: T FIRST NAME: Dev
ADDRESS: tttttttttt TOWN/CITY: chennai 2024-02-15
APPT.DATE:
POSTAL: 42424 PHONE: 8438413969 APPT.TIME: 16:25:00
HEALTHCARD: 12345 DATE OF BIRTH:
*please provide 48 hours notice of cancellation
MALE FEMALE
* no appointment or preparation please advise staff if you are * by appointment,and
X-RAY required or may be pregnant
ULTRASOUND see preparations at back
HEAD + NECK SPIN + PELVIS UPPEREXTREMITIES OBSTETRICAL SMALL PARTS
Complete
Sinuses Cervical Spine R L Shoulder Parathyroid
Obstetrical
Skull Thoracic Spine R L Clavicle 18-20 weeks Thyroid
Facial Bones Lumbar Spine AC Joint Dating Scrotum
Nose Sacrum + Coccyx R L Scapula High Risk
Mandible S-I Joints R L Humerus Complications MUSCULOSKELETAL
IPS(Nuchal
TM Joints Pelvis(One View) R L Elbow R L Shoulder
Transluency)
Adenoids R Hip + Pelvis R L Forearm Biophysical Profile R L Elbow
Neck for Soft
L Hip + Pelvis R L Wrist R L Wrist
Tissue
Orbits R L Scaphoid PELVIC R L Knee
Transabdominal +
Orbits -Pre-MRI SKELETAL SURVEY R L Hand R L Foot
Transvaginal
(Unless
Arthritic R L Digit R L Achilles Tendon
Contranidicated)
ABDOMINAL Metatastic R L Hamstring
KUB Bone Age R L Lumps/Masses
Acute Abdomen ABDOMINAL
OTHER EXAMS OR
CHEST LOWER EXTREMITIES Abdominal CARDIAC TESTING
VIEWS
Chest PA +LAT R L hip Abdomen + Pelvis Erchocardiography
Chest PA Ins
1 R L Femur
+EXP +LAT
Chest PA R L Knee
Sternum SC
R L Tibia + Fibula PROSTATE
joint
(incl.kidneys +
R Ribs+ Chest PA R L Ankle OTHER EXAMINATIONS
bladder)
L Ribs+ Chest PA R L Foot Transabdominal 2
immigration R L Calcaneus Transrectal
R L Toes
* walk ins welcome,
* By appointment,and BONE MINERAL
VASCULAR ULTRASOUND see preparations at back
appointment
DENSITY(DEXA) preferred
HEAD + NECK EXTREMITIES EXTREMITIES Baseline Once in a lifetime
(Peripheral
Arterial (Peripheral Venous) 2nd Test Low Risk 3 yrs after Baseline
Atterial)
Subsequent Low 5yrs after 2nd Test Low
(Carotids+Vertebrals) Arm Arm leg
Risk Risk
leg:Superficial Subsequent High Can be requested
Carotid Intimal
Venous Risk annually
OTHER * By appointment,and
Thickness (Varicose Veins) BREAST IMAGING
EXAMINATIONS see preparations at back
leg:Deep Venous Diagnostic Contact patient directly
Transcranial Doppler
Sys.(DVT) Mammogram if
Dialysis Fistula or
Stroke/TIA Protocol Bilateral more views required
Graft
(Transcranial Doppler, R L Arm Right
Carotid,Echocardiogram) R L Leg Left
ABDOMEN
Renal Arteries Implants Other: 4 other
Abdominal Aorta Ultrasound
Mesenteric Arteries Bilateral
Right
Left
Implants
CLINICAL HISTORY REQUESTED REFERRING PHYSICIAN STAT VERBAL
WSIB NAME OF DOCTOR DOCTOR'S SIGNATURE
dctr
phone FAX/EMERGENCY TEL.
657567 546
COPY TO: name Fax
dev 54674
Request CD Follow-up Frequency
PATIENT PREPARATION INSTRUCTIONS
ULTRASOUND PREPARATIONS APPOINTMENTS
ABDOMEN, ABDOMINAL AORTA, RENAL ARTERIES Please follow preparations carefully:
Avoid excess fats the night prior to the exam and solid
foods 8 hours before the exam. Small quantities of clear • We reserve the right to refuse and reschedule services due
fluids are permitted. (Any medication should be taken as to
required) circumstances such as arrival time, equipment downtime,
patient/equipment weight capacities, etc.
PELVIC ONLY - FEMALE & MALE • Please allow approx 45 minutes for each exam.
One hour prior to exam, drink 4 cups of water (total 32
oz). Do NOT empty bladder. • Please arrive 20 minutes prior to your schedule
appointment time
in order to register and to complete any necessary
paperwork.
• 48 hours cancellation is required for cancellations
otherwise a $50
charge will apply.
PROSTATE-TRANSRECTAL
• Reports will be sent to the referring physician within 2-3
days.
Urgent cases will be forwarded as soon as possible
ABDOMEN & PELVIC - SAME VISIT • Ministry of Health guidelines restrict the release of reports
directly
to patients
MIDLAND-ELLESMERE X-RAY & ULTRASOUND
SCARBOROUGH WOMEN'S IMAGING CENTRE
SCARBOROUGH VASCULAR ULTRASOUND
PREGNANCY We are located on the NE corner of Midland & Ellesmere.
South of Hwy 401, steps away from either the Midland RT
station and close to Scarborough General Hospital. We are on
the second floor of the Midland Professional building, suite
200. Free Parking is available. Snow Free driving surfaces.
We are wheelchair accessible.
Adult Echocardiogram, Scrotum, Thyroid & Neck,
Parathyroid,'Salivary Glands, Neonatal Hips, Musculo-
Skeletal, Cardiac Testing, Vascular Ultrasound (Head,
Neck & Extremities), Mammography, BMD No
preparation required
