CVDC
Credit Valley Diagnostic Centres
Appointment Details
ABDOMEN
K.U.B (1 view)
Acute (2-3 views)
HEAD & NECK
Skull
Sinuses
Adenoids
Orbits
Facial Bones
Nose
Mandible
Soft Tissue Neck
SPINE AND PELVIS
Cervical Spine
Thoracic Spine
Lumbosacral Spine
Sacrum/ Coccyx
S.I. Joints
Pelvis
Pelvis & Hips
CHEST
Chest
Ribs
L
R
Sternum
S.C. Joints
MAMMOGRAPHY C.A.R ACCREDITED
Diagnosis
Screening
Ontario Breast Screening Program (Over 50)
BONE DENSITOMETRY
AP spine & Femur
1st Baseline BM Din Ontario
Low Risk (2nd test-36 months)
Low Risk (3rd+test-60 months)
Hight Risk (once every 12 months)
Low Risk (3rd+test-60 months)
UPPER EXTREMITIES
Clavicle
L
R
A.C. Joints
L
R
Shoulder
L
R
Scapula
L
R
Humerus
L
R
Elbow
L
R
Forearm
L
R
Wrist
L
R
Hand
L
R
Thumb
L
R
L
R
Finger No.
Scaphold
L
R
Bone Age
LOWER EXTREMETIES
Hip
L
R
Femur
L
R
Knee
L
R
Tib. & Fib.
L
R
ANkle
L
R
Foot
L
R
Toe
L
R
Toe No.
Calcaneus
L
R
ULTRASOUND
Abdomen
Ltd. Abd. Area of Interest
Kidneys & Bladder Only
Pelvic - Male or Female
Transvaginal
IPS
Hernia
Routine Obstetrical
Targeted Obstetrical
Targeted Obstetrical
Biophysical Profile
Thyroid/Neck
Breast
Testes/Scrotum
Soft Tissue Lump
MSK
MSK
ECHOCARDIOGRAM
LVH/Cardiomyopathy
Murmur/Valvular Heart Disease
SOB/CHF
Syncope/Arrhythmia/Palpitations
Chest Pain/Coronary Disease
Stroke, suspected embolic event
Others (Please State)
Others (Please State)
CLINICAL INFORMATION
VERBAL
VERBAL
Doctor's Phone #
*
Please enter a valid phone number.
Patient First Name
*
Patient's Last Name
*
Initials
First Name
Last Name
Health Card Number
Patient's Birth Date
-
Month
-
Day
Year
Date
Patient's Sex
M
F
Patient's Phone Number
Patient's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
W.C.B Claim Number
Social Insurance Number
Account Date
-
Month
-
Day
Year
Date
Employer Name and Address
M.D. Date
*
-
Month
-
Day
Year
Date
Signature
MAMMOGRAM AND BONE DENSITY PREPARATIONS
MAMOGRAPHY
ONE DENSITOMETRY
ULTRASOUND PREPARATIONS
PELVIC
ABDOMEN
ABDOMINAL AND PELVIC
BREAST, TESTES, THYROID OR NECK
OBSTETRICAL
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