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Diagnostic Services Forms
Requisition Forms
Name |
Number |
Language |
|---|---|---|
| Outpatient Requisition X-Ray/ Ultrasound / Mammography | RHC 204 | English |
| Outpatient CT Scan Consultation Request | RHC 607 | English |
| Tissue Requisition | RHC 691 | English |
| Transfusion Medicine Requisition | RHC 779 | English |
| Cardiorespiratory Services Requisition (ECG/Holter Monitor/Stress Testing) | RHC 1107 | English |
| Nuclear Medicine Requisition | RHC 1109 | English |
| Electroencephalograph Requisition | RHC 1155 | English |
| MRI Requisition | RHC 1243 | English |
| Bone Mineral Density Requisition | RHC 1946 | English |
| Cytology & HPV Testing Requisition | RHC 2425 | English |
| Outpatient Echocardiography Requisition | RHC 2915 | English |
Questionnaires
Name |
Number |
Language |
|---|---|---|
| Mammography Questionnaire – Pertinent Patient History | RHC 407 | English |
| MRI Screening Information Form | RHC 1241 | English |
Patient Information Forms
Name |
Number |
Language |
|---|---|---|
| Barium Enema – Outpatient | RHC 229 | English |
| Semen Fluid Analysis Collection Instructions | RHC 270 | English |
| Stream Urine Collection Instructions | RHC 271 | English |
| Stool Collection for C&S (Cary Blair with Indicator) | RHC 860 | English |
| Midstream Urine Collection Instructions for Cytology | RHC 952 | English |
| 24 Hour Urine Collection Instructions | RHC 954 | English |
| Sputum Collection Instructions for Cytology | RHC 971 | English |
| Stool Collection Instructions for Clostridium Difficile | RHC 975 | English |
| Sputum Collection Instructions for Culture and Sensitivity | RHC 2039 | English |
| Stool Collection Instructions for Occult Blood | RHC 2040 | English |
| Glucose Tolerance Testing Collection Instructions | RHC 2683 | English |
| Patient Instructions For Intravenous Contrast Extravasation | RHC 2954 | English |
| Random Urine Collection Instructions | RHC 3098 | English |
Pre-Printed Physician’s Orders
Name |
Number |
Language |
|---|---|---|
| Therapeutic Phlebotomy | PPO-6-074 | English |
Other Forms
Name |
Number |
Language |
|---|---|---|
| Adult Transthoracic Echo Final Report | RHC 2904 | English |
North Bay
50 College Drive,
P.O. Box 2500
North Bay, ON
P1B 5A4
Tel: 705-474-8600
Sudbury
680 Kirkwood Drive,
Sudbury, ON
P3E 1X3
Tel: 705-675-9193
Fax: 705-675-6817
