Req Form IRM Sud Ouest

Req Form IRM Sud Ouest - Clinique dimagerie par rsonance...

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Unformatted text preview: Clinique dimagerie par rsonance magntique irm sud-ouest 5515, rue Saint-Jacques Ouest, bureau 200 Montral (Qubec) H4A 2E3 Tl. : 514 484-8484 info@irmsudouest.com Fax : 514 484-8400 www.irmsudouest.com Nom / Family Name Prnom / First Name Nom la naissance / Maiden Name DDN / DOB / / Adresse / Address Tl. rs. / Tel. Home ( ) Bur. / Off. ( ) Formulaire de rquisition / Requisition Form n CSST n SAAQ N o de dossier / File Number Date de lvnement / Date of Event Nom de lagent / Agent Name Tlc. / Fax ( ) n Avec contraste / With Contrast Une cratinine est demande pour tout patient ncessitant une injection de gadolinium si vous souffrez de diabte, tes sur la dialyse, avez une fonction rnale anormale ou g de 50 ans et plus. Un test sanguin doit tre effectu et les rsultats doivent tre envoys la clinique avant lexamen. / For patients undergoing an MRI with an injection of gadolinium. If the patient is diabetic, undergoes dialysis, has abnormal renal function, or is 50 years of age and over, a serum creatinine level must be done prior and the results received at the clinic before the exam can be performed. Renseignements cliniques / Clinical Notes A/Y M/M J/D n Cerveau / Brain n Selles turcique-hypophyse / Sella Turcica-pituitary n Charnire cranio-vertbrale / Base of Skull n Orbites / Orbits n Articulations T-M / T-M Joints n CAI / IACs n Parotides / Parotids n Sinus / Sinuses n Nasopharynx n Cou-ORL / Neck-ENT n Plexus brachial / Brachial Plexus n Autre / Other n Sein / Breast Prcisez le ct / Specify Side n Abdomen n Thorax / Chest n Angiographie R-M / MR Angiography Spcifiez / Specify Location n Colonne cervicale / Cervical Spine n Colonne dorsale / Thoracic Spine n Colonne lombo-sacre / Lumbosacral Spine IRM / MRI Mdecin requrant / Referring Physician Date Tl. / Tel. ( ) N o Licence / License No. Licence / License No....
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Req Form IRM Sud Ouest - Clinique dimagerie par rsonance...

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