{"id":12114,"date":"2016-03-29T13:48:35","date_gmt":"2016-03-29T17:48:35","guid":{"rendered":"http:\/\/www.nbrhc.on.ca\/fr\/formulaires-pour-les-fournisseuses-et-fournisseurs-de-soins-de-sante\/diagnostic-imaging-forms\/"},"modified":"2026-04-09T15:41:32","modified_gmt":"2026-04-09T19:41:32","slug":"formulaire-services-dimagerie-diagnostique","status":"publish","type":"page","link":"https:\/\/nbrhc.on.ca\/fr\/formulaires-pour-les-fournisseuses-et-fournisseurs-de-soins-de-sante\/formulaire-services-dimagerie-diagnostique\/","title":{"rendered":"Formulaires de services d’imagerie diagnostique"},"content":{"rendered":"

Formulaires de demande<\/h2>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

Nom<\/h3>\n<\/th>\n

\n

Num\u00e9ro<\/h3>\n<\/th>\n

\n

Langue<\/h3>\n<\/th>\n<\/tr>\n<\/thead>\n

Outpatient Requisition X-Ray\/ Ultrasound \/ Mammography<\/a><\/td>\nRHC\u00a0204<\/td>\nanglais<\/td>\n<\/tr>\n
Tissue Requisition<\/a><\/td>\nRHC\u00a0691<\/td>\nanglais<\/td>\n<\/tr>\n
Transfusion Medicine Requisition<\/a><\/td>\nRHC 779<\/td>\nanglais<\/td>\n<\/tr>\n
Cardiorespiratory Services Requisition (ECG\/Holter Monitor\/Stress Testing)<\/a><\/td>\nRHC 1107<\/td>\nfran\u00e7ais<\/td>\n<\/tr>\n
Nuclear Medicine Requisition<\/a><\/td>\nRHC 1109<\/td>\nanglais<\/td>\n<\/tr>\n
Electroencephalograph Requisition<\/a><\/td>\nRHC 1155<\/td>\nanglais<\/td>\n<\/tr>\n
Bone Mineral Density Requisition<\/a><\/td>\nRHC 1946<\/td>\nfran\u00e7ais<\/td>\n<\/tr>\n
Cytology & HPV Testing Requisition<\/a><\/td>\nRHC\u00a02425<\/td>\nanglais<\/td>\n<\/tr>\n
Outpatient Echocardiography Requisition<\/a><\/td>\nRHC 2915<\/td>\nanglais<\/td>\n<\/tr>\n
Formulaire de demande de scanner pour patients externe<\/a><\/td>\n–<\/td>\nfran\u00e7ais<\/td>\n<\/tr>\n
Formulaire de demande d’IRM en ambulatoire<\/a><\/td>\n–<\/td>\nfran\u00e7ais<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Questionnaires<\/h2>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
\n

Nom<\/h3>\n<\/th>\n

\n

Num\u00e9ro<\/h3>\n<\/th>\n

\n

Langue<\/h3>\n<\/th>\n<\/tr>\n<\/thead>\n

Questionnaire relatif \u00e0 une mammographie – Ant\u00e9c\u00e9dents pertinents<\/a><\/td>\nRHC 407<\/td>\nfran\u00e7ais<\/td>\n<\/tr>\n
MRI Screening Information Form<\/a><\/td>\nRHC\u00a01241<\/td>\nfran\u00e7ais<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Formulaire d’information des patients<\/h2>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

Nom<\/h3>\n<\/th>\n

\n

Num\u00e9ro<\/h3>\n<\/th>\n

\n

Langue<\/h3>\n<\/th>\n<\/tr>\n<\/thead>\n

Barium Enema – Outpatient<\/a><\/td>\nRHC 229<\/td>\nfran\u00e7ais<\/td>\n<\/tr>\n
Semen Fluid Analysis Collection Instructions<\/a><\/td>\nRHC 270<\/td>\nanglais<\/td>\n<\/tr>\n
Stream Urine Collection Instructions<\/a><\/td>\nRHC\u00a0271<\/td>\nanglais<\/td>\n<\/tr>\n
Stool Collection for C&S (Cary Blair with Indicator)<\/a><\/td>\nRHC\u00a0860<\/td>\nfran\u00e7ais<\/td>\n<\/tr>\n
Midstream Urine Collection Instructions for Cytology<\/a><\/td>\nRHC\u00a0952<\/td>\nfran\u00e7ais<\/td>\n<\/tr>\n
24 Hour Urine Collection Instructions<\/a><\/td>\nRHC\u00a0954<\/td>\nanglais<\/td>\n<\/tr>\n
Sputum Collection Instructions for Cytology<\/a><\/td>\nRHC\u00a0971<\/td>\nanglais<\/td>\n<\/tr>\n
Stool Collection Instructions for Clostridium Difficile<\/a><\/td>\nRHC\u00a0975<\/td>\nanglais<\/td>\n<\/tr>\n
Sputum Collection Instructions for Culture and Sensitivity<\/a><\/td>\nRHC\u00a02039<\/td>\nanglais<\/td>\n<\/tr>\n
Stool Collection Instructions for Occult Blood<\/a><\/td>\nRHC\u00a02040<\/td>\nanglais<\/td>\n<\/tr>\n
Glucose Tolerance Testing Collection Instructions<\/a><\/td>\nRHC 2683<\/td>\nfran\u00e7ais<\/td>\n<\/tr>\n
Patient Instructions for Intravenous Contrast Extravasation<\/a><\/td>\nRHC 2954<\/td>\nanglais<\/td>\n<\/tr>\n
Random Urine Collection Instructions<\/a><\/td>\nRHC 3098<\/td>\nanglais<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Ordres du m\u00e9decin pr\u00e9imprim\u00e9s<\/h2>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

Nom<\/h3>\n<\/th>\n

\n

Num\u00e9ro<\/h3>\n<\/th>\n

\n

Langue<\/h3>\n<\/th>\n<\/tr>\n<\/thead>\n

Therapeutic Phlebotomy<\/a><\/td>\nPPO-6-074<\/td>\nanglais<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Autres formulaires<\/h2>\n\n\n\n\n<\/colgroup>\n\n\n\n\n
\n

Nom<\/h3>\n<\/th>\n

\n

Num\u00e9ro<\/h3>\n<\/th>\n

\n

Langue<\/h3>\n<\/th>\n<\/tr>\n<\/thead>\n

Adult Transthoracic Echo Final Report<\/a><\/td>\nRHC 2904<\/td>\nanglais<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n","protected":false},"excerpt":{"rendered":"

Formulaires de r\u00e9f\u00e9rence, demandes, d’information et autres formulaires pour les services d’imagerie diagnostique (\u00c9chocardiographie, \u00c9chographie, IRM, ECG\u00e9EEG, Mammographie et Padiographies) et les services de laboratoire.<\/p>\n","protected":false},"author":17,"featured_media":0,"parent":5962,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":"","_links_to":"","_links_to_target":"","_wp_rev_ctl_limit":""},"tags":[1559,1577,1565,1575,1571,1573,1557,1583,2418,2617,2480,2489,2640,2631,2689,1579,1560,1578,1566,1576,1572,1574,1558,1584,2419,2481,2488,2641,2690,1580],"class_list":["post-12114","page","type-page","status-publish","hentry","tag-rhc-1107-fr","tag-rhc-1109-fr","tag-rhc-1155-fr","tag-rhc-1241-fr","tag-rhc-1242-fr","tag-rhc-1243-fr","tag-rhc-1946-fr","tag-rhc-204-fr","tag-rhc-229-fr","tag-rhc-2594-fr","tag-rhc-2904-fr","tag-rhc-2915-fr","tag-rhc-2954-fr","tag-rhc-3098-fr","tag-rhc-407-2","tag-rhc-607-fr","tag-rhc1107-fr","tag-rhc1109-fr","tag-rhc1155-fr","tag-rhc1241-fr","tag-rhc1242-fr","tag-rhc1243-fr","tag-rhc1946-fr","tag-rhc204-fr","tag-rhc229-fr","tag-rhc2904-fr","tag-rhc2915-fr","tag-rhc2954-fr","tag-rhc407-2","tag-rhc607-fr"],"acf":[],"yoast_head":"\nFormulaires de services d'imagerie diagnostique - 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