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Manitoba CT Request Form R250-10-115

Since January 30, 2026, Shared Health requires this standardized form for all urgent and elective CT examinations performed in Manitoba. The same form serves outpatient, emergency and inpatient requests, and asks for scheduling details, clinical and surgical history, contrast allergy and renal risk screening. Outpatient requests for Winnipeg sites go through Diagnostic Imaging Central Intake, which forwards them to the site with the shortest wait.

Who completes it

The ordering clinician completes and signs the whole form, including patient details, urgency, exam, history, renal risk and a 24-hour critical results contact. Clerical staff add the visit number.

Submitting and payment

How to submit it
Fax requests for exams in Winnipeg to Diagnostic Imaging Central Intake, and requests for exams elsewhere to the nearest diagnostic imaging department providing CT. For exams needed within a week, contact the imaging site first and fax only to that site, because Central Intake needs at least 24 hours.
Who pays
The ordering clinician block asks for a billing number, and the quick reference guide lists billing codes among the required information; the form sets out no patient fee.

Good to know

  • Relevant clinical and surgical history must never be blank: radiologists use it to set priority, scheduling and protocol, and incomplete or unreadable asterisked fields send the form back to the referrer.
  • Renal risk screening asks about known kidney disease and prior or pending renal referral; if both answers are no, creatinine is not required, and stable results up to six months old are accepted.
  • Urgency guides but does not set priority: emergent means within 24 hours by direct radiologist contact, urgent within 7 to 30 days, and elective the next available slot.
  • Patient weight is always required, and must be a recent accurate weight for patients 250 lbs or more. Unless stated otherwise, patients are assumed willing to travel to a site with a shorter wait.

Get the official form

Download the current version from the source each time; forms change without notice.

CT Request Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

See how Vero Documents works

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Which form do I use for X-ray or ultrasound in Manitoba?

Not R250-10-115. Shared Health directs that X-ray, ultrasound and nuclear medicine exams in Winnipeg use the Request for Diagnostic Imaging Exam (SAP #299189), and exams outside Winnipeg use R250-10-116, Request for DI Examination (Rural). MRI has its own MRI Request Form, and older printed or saved DI requisitions should be discarded.

Can I choose a specific CT site for my patient?

Yes. The outpatient section lets you request the first available appointment in Winnipeg, mark the patient as willing to travel within Manitoba, or name a preferred site. If you have spoken with a radiologist, write their last name and site above the preferred site line, as the practice change memo instructs.

Does the patient need bloodwork before a contrast CT in Manitoba?

Not always. The quick reference guide says creatinine testing is not required when both renal screening questions are answered no. If either is yes, the form asks for the most recent serum creatinine and eGFR, or a point-of-care result, with its date; results up to six months old are acceptable for patients at baseline.