Fillable REQUEST FOR EXAMINATION SOUTHWESTERN ONTARIO PATIENT INFORMATION (AFFIX

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REQUEST FOR EXAMINATION SOUTHWESTERN ONTARIO PATIENT INFORMATION (AFFIX

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CARDIOLOGY
ULTRASOUND
X-RAY (WALK-IN SERVICE)
NUCLEAR CARDIOLOGY
MYOCARDIAL PERFUSION
Exercise 
Dobutamine
MYOCARDIAL VIABILITY
Thallium Viability
Study
VENTRICULAR FUNCTION
Rest MUGA - Simcoe
CARDIOLOGY CONSULTATION
NUCLEAR MEDICINE (SIMCOE)
BONE SCAN
Total Body

SPECT
GALLIUM
Total Body

SPECT
RENAL
Captopril Renal
Lasix Renal

ENDOCRINE
Thyroid Scan Only
Thyroid Uptake & Scan
Parathyroid
MISCELLANEOUS
V/Q Lung Scan
Hyperthyroidism

Salivary Scan
Gallbladder/Biliary Scan
Gastric Emptying Scan
Liver/Spleen Scan
GASTROINTESTINAL
Hemangioma Scan
G.I. Bleeding Scan
Meckel’s Scan
MAMMOGRAPHY & BONE MINERAL DENSITY
R
L
Shoulder
Clavicle
Sternoclavicular joints
A.C. Joint
Scapula
Humerus
Elbow
Wrist
Scaphoid
Hand

R
L
Hip
Femur
Knee
Tib. & Fib.
Ankle
Foot
Calcaneus

Skull
Sinuses


Mandible
Orbits
T.M. Joints
Chest PA & LAT
Ribs R L
Sternum
Chest Visa
Single/KUB
Acute

OTHER:
Facial Bones

ABDOMINAL
CHEST
HEAD & NECK
Adenoids
Mastoids
Cervical Spine
Thoracic Spine

Sacrum/Coccyx
S.I. Joints
Pelvis
LOWER EXTREMITIES
SPINE & PELVIS
SKELETAL SURVEY
UPPER EXTREMITIES
R
L
Forearm
Bone Age
Scoliosis Series


US GUIDED PROCEDURES


OTHER:
VASCULAR
R
L







Renal Arteries
Portal Venous Doppler
OBSTETRICAL
 
Anatomic 



Dual Scan Series 

Follicular Studies
PELVIS
Female Pelvis

Male Pelvis 
Prostate 
GENERAL ULTRASOUND
Abdomen + Pelvis

Abdomen 

Kidneys*
Bladder

*Baseline abdominal ultrasound may be performed
SMALL PARTS
Face
Chest

Groin/Inguinal
Testes/Scrotum


Female Breast** R L
R L

**This is not an approved cancer screening tool


MUSCULOSKELETAL
R
L
Elbow
Wrist
Hamstring
Knee
Popliteal Fossa
Ankle
Achilles Tendon
Plantar Fascia

NEONATAL
Hip

Pyloric Stenosis 
Spine 

REFERRING PHYSICIAN INFORMATION (STAMP LABEL IF AVAILABLE)

URGENT


  
 
 
   

PATIENT INFORMATION (AFFIX LABEL IF AVAILABLE)

or visit MyHealthCentre.ca
ACCREDITED WITH
COMMENDATION
REQUEST FOR EXAMINATION – SOUTHWESTERN ONTARIO

 
 
 

 

Fax HRM

Chest pain suspicious of CAD

Hypertension
Murmur

Syncope

Contrast Echocardiogram
Mammogram
Implants

R L
BONE MINERAL DENSITY
Baseline Study
Follow Up High Risk







Holter Monitoring


- Simcoe
Pre & Post Spirometry
Include Respirology Consult

Coronary CT Calcium Score 
- Mississauga PET/CT
Stress Echocardiogram

First Available
Dr.

London Southdale

Delhi

London Fanshawe
Sarnia
London Arva
Simcoe


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



Access your radiology images and reports

BRANTFORD



Avenue/Cainsville exit
T: 519-805-3560 | F: 519-805-3561

SERVICES: Blood Pressure Monitoring, Cardiology

Exercise Stress Test, Holter Monitoring
LONDON SOUTHDALE



Southdale Road
T: 226-663-2933 | F: 226-663-4561

SERVICES: Prenatal Screening, Ultrasound,

LONDON ARVA


Richmond Street, north of the London Masonville Mall
T: 519-672-0070 | F: 519-850-0144

SERVICES: Blood Pressure Monitoring, Cardiology

Exercise Stress Test, Holter Monitoring, Prenatal
Screening, Stress Echocardiogram, Ultrasound
SARNIA



T: 519-336-8110 | F: 519-336-3241

SERVICES: Bone Mineral Density, Mammography &



DELHI


Delhi Community Health Centre on Main Street,
north of King Street
T: 519-428-1243 | F: 519-428-2445

SERVICES: Ultrasound, Vascular Ultrasound
LONDON FANSHAWE



of Hyde Park Road
T: 519-439-5555 | F: 519-266-2206

SERVICES: Bone Mineral Density, Mammography,



LONDON WHARNCLIFFE (IMAGING)



T: 519-661-0275 | F: 519-661-0616

SERVICES:
Mammography & OBSP, Prenatal Screening,


LONDON WHARNCLIFFE (CARDIOLOGY)



T: 519-858-7476 | F: 519-266-6739
E:

SERVICES: Blood Pressure Monitoring, Cardiology

Exercise Stress Test, Holter Monitoring,
Stress Echocardiogram
SIMCOE


West Street Health Centre at the corner of Queen
and West Street
T: 519-428-1243 | F: 519-428-2445

SERVICES: Blood Pressure Monitoring, Bone Mineral

Electrocardiogram, Exercise Stress Test, Holter

Prenatal Screening, Pulmonary Function Test,




MyHealthCentre.ca.
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REQUEST FOR EXAMINATION SOUTHWESTERN ONTARIO PATIENT INFORMATION (AFFIX

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Completed 20 April 2021

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