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CENTRAL BOOKING
780-669-2222
Toll Free: 1-866-771-9446
Fax: 780-930-1593
*no appointment needed
for general x-ray
Please keep your appointment. If you don’t cancel 24 hours prior to exam, you may be charged a $25.00 fee. Remember that others with healthcare needs could use your appointment time.
FREE PARKING ALL SITES
NAME: __________________________________________________________ CALLINGWOOD X-RAY
ADDRESS: ______________________________________________________ PHONE: __________________ DATE OF BIRTH: _______________ M F INSIGHT - MEADOWLARK
INSURANCE: ___________________ W.C.B. ( ) OTHER: ________________ Includes MEADOWLARK CARDIAC LAB and
X-RAY • ALL SITES
PAIN MANAGEMENT
MEADOWLARK MRI and CT
INSIGHT - WEST END
ULTRASOUND
InsIght Lendrum women’s ImagIng
SMALL PARTS
OBSTETRICS
VASCULAR
CALGARY TRAIL X-RAY
INSIGHT - HERITAGE SOUTH
INSIGHT - MILLWOODS
NUCLEAR MEDICINE
 Bone Scan - (15 min., return 2-4 hours later for 30-60 min.)  Cardiac Resting Gated Blood Pool Study (90 min.) BELVEDERE X-RAY
 Parathyroid Scan (30 min.-return in 2 hrs for 30 min.)  HIDA (Hepatobiliary) + GBEF (2-4 hours) INSIGHT - CASTLEDOWNS
 MIBI - Myocardial Perfusion Scan (Meadowlark, Millwoods, Ft. Mac.)  Liver RBC Scan for hemangioma (40 min-return in 2 hrs for 1 hour) Ph: 780-457-4070 | F: 780-456-1250
INSIGHT - HERMITAGE NORTH
MAMMOGRAPHY
DENSITOMETRY
CAPILANO X-RAY
CARDIAC DIAGNOSTICS • MEADOWLARK (all) • MILLWOODS (MIBI only) • FORT MCMURRAY (MIBI only)
 Ambulatory Blood Pressure Monitoring (not covered by AHCIP) SPRUCE GROVE
MRI & CT • MEADOWLARK (MRI and CT not covered by Alberta Health)
 CT anatomic area to be studied _______________  Virtual Colonoscopy (CT Colonography)  MRI anatomic area to be studied ______________ SHERWOOD PARK
 Lung CT screen (smoker, second-hand smoke) RELEVANT HISTORY, PHYSICAL FINDINGS, AND PROVISIONAL DIAGNOSIS  STAT FAX REPORT (until 16:00)
FORT MCMURRAY
 SEND IMAGES WITH PATIENT COPY OF REPORT TO SIGNATURE OF PHONE: _____________________
REFERRING DR. _________________________ FAX: ________________________
Extended hours of operation for x-ray only.
PREGNANT? NO  YES  LMP ____________________ Pt. Sign _______________________________ IMAGES SEE REVERSE SIDE FOR EXAMINATION INSTRUCTIONS
ver 42, Jan 2013
FREE PARKING ALL SITES
EXAMINATION INSTRUCTIONS
The following examinations are by appointment only. When making appointment, please notify if patient is diabetic.
** ALL EXAMINATIONS **
Please bring this signed request with you. If you are unable to keep your appointment, please phone 780-669-2222 to reschedule it.
There is no facility to look after small children.
STOMACH AND DUODENUM (S&D), ESOPHAGUS (E), UPPER GI (UGI), or SMALL BOWEL (SB FT)
Morning Appointment - Do not eat or drink anything after midnight the night before the examination.
Small Bowel exams may take up to three hours to complete.
COLON EXAMINATION (Barium enema)
Two days before the examination unrestricted amounts of clear liquids only (e.g. water, clear juice, Gatorade, Powerade,
consomme, tea, coffee or jello); No Solid Foods
Day before the examination unrestricted amounts of clear liquids only (e.g. water, clear juice, Gatorade, Powerade, consomme,
tea, coffee or jello); No Solid Foods
at 5:00 p.m. drink one bottle of Magnesium Citrate laxative; at 7:00 p.m. take 3 Dulcolax tablets (5 mg). Do not crush or chew tablets. Continue with a liquid diet for the rest of the day; Day of colon examination: You may have one glass of water or clear juice. Eat nothing until the examination is completed.
* DIABETIC PATIENTS should consult their physician regarding possible stoppage or reduction of insulin while
fasting on “clear liquids only” diet.
* Please continue to take your regular medications
DIAGNOSTIC ULTRASOUND EXAMINATIONS
1. OBSTETRICAL OR PELVIC – IMPORTANT: THE BLADDER MUST BE FULL.
1 1/2 hours prior to the examination drink FOUR 250 ml glasses of water and refrain from urinating. Finish all glasses of water
2. ABDOMINAL
For morning appointment: nothing to eat or drink after midnight or the morning of the examination. For afternoon appointments: a light breakfast of toast, coffee or tea (no dairy products) 6 hours prior to the examination.
3. ABDOMEN & PELVIC / RENAL & BLADDER
Nothing to eat for 6 hours prior to the examination, but 1 1/2 hours prior to the examination drink SIX 250 ml glasses of
water and refrain from urinating. Finish all glasses of water 1 hour before time of examination.
NUCLEAR MEDICINE EXAMINATIONS
Bone Scan: . Bring most recent x-rays.
Gallium Scan:. Day 1 injection; Day 4 one hour imaging.
HIDA (Hepatobiliary) Scan: . Nothing by mouth from midnight.
Liver RBC Scan:. No Barium intestinal tests for one week prior to scan.
Lung Scan: . Bring most recent chest x-rays.
Thyroid Scan:. Must NOT be taking thyroid medications for 4 weeks prior to
scan. Need results of thyroid blood test at time of scan.
Myocardial Perfusion Scan:. No eating or drinking 4 hours prior to exam. No beverages or food
containing caffeine for 24 hours prior.
Renal Scan / Renogram: . Drink 3 cups of fluids in half hour prior to examination.
Other Scans:. Need no preparation unless informed at time of booking.
* If you are breast feeding, please talk to the technologist prior to the injection.
MAMMOGRAPHY
Do not use deodorant, antiperspirant or talcum before the examination. Stay on a caf eine free diet to minimize discomfort of
compression required for optimal examination. Premenstrual breast tenderness - you may delay booking until tenderness has subsided. Wear a two-piece outfit. At time of booking advise where previous mammogram was done and if possible allow appropriate time for films to arrive before appointment date.
Please notify your doctor if you have any of the following: pacemaker, aneurysm clips, welding history, eye injury with metal.
Abdominal Examinations: Clear fluids only for 6 hours before examination. No preparation for other CT examinations.

Source: http://www.x-ray.ca/_pdf/Insight_exam_requisition.pdf