Manitoba's requisition for MRI examinations; non-emergent requests are faxed to Diagnostic Imaging Central Intake, which sends each to an appropriate site with the shortest wait. Besides patient, scheduling and exam details, it includes MRI safety pre-screening for implants and metal, renal questions for IV contrast, and pediatric sedation prompts. Version V03 has been in effect since May 1, 2019.
The referring clinician completes and signs the form, including the asterisked patient, weight, height, allergy, exam and clinical history fields. The referring office attaches implant records and any orbital X-ray report.
Download the current version from the source each time; forms change without notice.
MRI Request Form
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Yes. The outpatient section offers the first available appointment in Winnipeg, willingness to travel within Manitoba for the first available slot, or a named preferred site. ED outpatient requests record the time the order was placed and whether follow-up is with the ED physician or the primary care provider.
The form states that incomplete or illegible forms will be returned and that asterisked information must be completed or the request will be declined. Required items include patient name, date of birth, sex, PHIN, daytime phone, weight, height, imaging-related allergies, the anatomical location or exam, relevant clinical and surgical history, and the clinician's signature and printed name.
Yes. The form directs research study requests to the Research Requisition Form rather than R130-80-04. Shared Health also publishes an MRI Requisition Reference Guide showing the mandatory fields, and an MRI Safety Checklist, on its diagnostic imaging central intake page.