Campbellford Memorial Hospital
146 OLIVER ROAD
CAMPBELLFORD, ON  K0L 1L0
MAP & DIRECTIONS
GENERAL INQUIRIES:
705-653-1140

Radiology Referral Forms

To ensure that the patient receives the appropriate examination, radiology procedures are completed after receiving a correctly completed order from a physician and/or a radiologist.

A patient’s requisition must be completed clearly stating patient’s demographics, the examination, as well as the relevant patient history and/or clinical findings, physician name and billing code. If documentation is incomplete, patients will not be booked and requisitions will be returned to the referring physician.

This information and history is essential for patient care; the MRT can select the appropriate views to confirm the suspected condition and the attending radiologist will have appropriate data for reporting.

Requisitions that conflict with the MRT's clinical experience and judgment are clarified with the radiologist or referring healthcare professional.

pdf CT Requisition (89 KB)

pdf Echocardiogram Requisition (210 KB)

pdf Diagnostic Imaging Requisition (182 KB) pdf (CLICK HERE FOR SPECIAL NOTE FOR BMD TEST) (147 KB)