APPOINTMENT REQUEST Please complete every field of the form. Date of birth:    (dd/mm/yyyy) Name and Surname: Phone number:    Fax number: (optional)    E-mail address: Health Insurance Number:   IMPORTANT: Please ask patient to bring his/her Medicare card on the day of the examination, making sure it is still valid EXAMINATION(S): CLINICAL INFORMATION PLEASE Mammography Galactography* Mammography Ultrasound Abdomen Breast Fetal (16 weeks or less) Hysterosonography Musculo-skeletal* Neck Nuchal translucency Pelvic Prostate Testicles Thyroid     Doppler Arterial* Carotids* Doppler evaluation of erectile dysfunction* Hepatic* Renal* Venous* 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) Abdomen* Brain* Coronary Calcium Scoring* Coronary CT angiography* Facial bones* Lumbar spine* Mastoids - Temporal Bones* Musculo-skeletal* Neck - ENT* Orbits* Pelvis* SI joints* Sinuses* Thorax* Virtual colonoscopy*     Bone densitometry 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 Arthrography* Barium enema Bursography* Facet block* Small bowel Therapeutic infiltrations* Upper G.I.     * 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.

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