Diagnostic Requisitions - Physicians only
This page is designed to allow physicians electronic access to the most current Diagnostic Imaging requisitions.
These requisition forms are for physicians to complete only. They are not intended for patients to complete.
No Diagnostic Imaging exam will be performed at any QHC hospital without a fully completed requisition signed by a licensed physician. Any requisition that appears fraudulent will be investigated immediately and imaging services WILL NOT be provided.
Please note we are in the process of updating our requisitions with new and improved versions (noted with "NEW"). Please fax all completed requisitions to 613-969-5561.
- Bone Mineral Density Requisition - NEW
- Breast MRI requisition - NEW
- Cardiopulmonary Requisition - NEW
- CT Requisition - NEW
- CT Colonography Requisition - NEW
- CT Cardiac requisition (temporarily unavailable)
- External Imaging Consult
- Interventional Radiology Requisition - NEW
- Mammography Requisition - NEW
- MRI Requisition - NEW
- Nuclear Cardiology Requisition - NEW
- Nuclear Medicine Requisition - NEW
- Ultrasound - NEW
- X-Ray Requisition - NEW