PATIENT INFORMATION

    First

    Last

    ADDRESS

    POSTAL CODE

    TELEPHONE

    DATE OF BIRTH

    SEX

    HEALTH CARD NUMBER

    VERSION CODE

    You must bring a completed Requisition Form and valid Health Card.

    Please arrive 10 minutes early to register

    CLINICAL INFORMATION - MANDATORY, AS PER CPSO

    ULTRASOUND

    General

    Obstetrical

    Vascular

    Children under 12 will be encouraged to go to CHEO for their ultrasound. This is the common practice in Ottawa as the pathology of children differs significantly than that of an adult.

    YOUR APPOINTMENT

    DATE

    TIME

    PREPARATION

    ULTRASOUND

    ABDOMEN:
    Nothing to eat or drink 8 hours prior to your appointment (except water to swallow necessary Medications).
    ABDOMEN & PELVIS:
    Nothing to eat for 8 hours prior to your appointment and you must complete drinking 40 ounces/1 Litre of water 1
    hour BEFORE your appointment. Do not void.
    PELVIS / OBSTETRICAL:
    A full bladder is necessary. FINISH drinking 40 ounces / 1 litre of clear fluid 1 hour BEFORE your appointment. Do not void. 
    MALE PELVIS:
    Patient to arrive with a full bladder. (Follow instructions for a pelvis exam.)
    NO PREPARATION REQUIRED:
    Abdomen Limited for Hernia, Thyroid, Testis, Soft Tissue Lump, MSK

    Children under 12 will be encouraged to go to CHEO for their ultrasound. This is the common practice in Ottawa as the pathology of children differs significantly than that of an adult.