Health PEI's provincial Diagnostic Imaging departments use one requisition for general radiography, CT, nuclear medicine, bone mineral density, mammography, ultrasound and MRI. The physician or nurse practitioner sets the priority, describes the exam and area of interest, and gives the provisional diagnosis, clinical history and relevant previous imaging. MRI requests also need the safety questions on the reverse.
The ordering physician or nurse practitioner completes the requisition and signs it, with office phone and fax numbers and any extra report recipient. Technologists and radiologists complete the department sections at the time of the exam.
Download the current version from the source each time; forms change without notice.
Request for Diagnostic Consultation
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Health PEI asks clinicians to fax urgent and semi-urgent x-ray requisitions to the QEH Diagnostic Imaging department; reception books the appointment and contacts the patient within 24 to 48 hours. Patients may go straight to the department for STAT x-rays only if they meet the STAT criteria, and the requisition must be marked STAT.
The form printed Q74-05 (01/21), with the identification code 101074-0005 (01/21). Health PEI revised it in 2021, adding booking numbers for every site, moving the malignancy question under clinical history, and adding DND and non-Canadian resident to billing. It asked sites to destroy older versions.