Radiologie Varad Montréal, Québec

Date of birth :

(dd/mm/yyyy)

Name and Surname :

Phone number :

Fax number : (optionnel)

E-mail address :

Health Insurance Number :

Mammography

Galactography*

Screening Mammography

Ultrasound and Doppler

Doppler

Magnetic resonance imaging (MRI)

	Abdomen*		Brachial plexus*
	Brain*		Breast*
	Carotids*		Circle of Willis*
	Cranio-vertebral junction*		Internal auditory canals*
	Musculo-skeletal*		Neck - ENT*
	Orbits*		Pelvis*
	Pituitary gland*		Spine (cervical, dorsal and/or lumbar)*
	Thorax*

Computed Tomography (CT Scan)

Osteodensitometry

General radiology

	Abdomen		Cavum
	Chest - Thorax		Facial Bones
	Lower extremeties		Metastatic survey
	Pelvis		SI Joints
	Sinuses		Skull
	Spine (cervical, dorsal and/or lumbar)		TM Joints
	Upper extremeties

Specialized radiology

Musculoskeletal Imaging

* For MRI or CT exams, please fax (514-281-0262) your requisition and we will contact your patient to set up an appointment.

Other examinations :

Availability :

Date :

Comments :

CONFIRMATION :

Please take note that we answer all appointment requests by email only.

4 Complexe Desjardins, Level 4, Montreal (Qc) | Phone : 514-281-1355 | Fax : 514-281-0262 | FRANÇAIS