Website: www.kmhlabs.com

905-855-1860 ♦ 1-877-KMH-LABS(564-5227)

LOCATIONS

BURLINGTON
3155 Harvester Road
Suite 106
Burlington, Ontario
L7N 3V2
Tel: 1-877-564-5227
Fax: 905-639-7521

HAMILTON
206 James street South
Suite 104
Hamilton, Ontario
L8P 3A9
Tel: 1-877-564-5227
Fax: 905-528-9973

KITCHENER
751-B Victoria Street S.
Suite 108
Kitchener, Ontario
N2M 5N4
Tel: 1-877-564-5227
Fax: 519-569-7069

MARKHAM
50 Minthorn Blvd.
Suite 101
Markham, Ontario
L3T 7X8
Tel: 1-877-564-5227
Fax: 905-731-6419

MISSISSAUGA
3075 Hadwen Road
Mississauga, Ontario
L5K 2L3
Tel: 905-855-1860
Fax: 905-855-1863

NORTH YORK
1310 Don Mills Road
Suite 5
North York, Ontario
M3B 2W6
Tel: 905-855-1860
Fax: 416-444-0896

SCARBOROUGH
55 Town Centre Court
Suite 109
Scarborough, Ontario
M1P 4X4
Tel: 905-855-1860
Fax: 416-290-0183

TORONTO
236 Avenue Road
Toronto, Ontario
M5R 2J4
Tel: 905-855-1860
Fax: 416-968-9709

PATIENT NAME: WEIGHT: HEIGHT:

1. Please complete
form and give to
patient

PATIENT PHONE: D.O.B.:
APPOINTMENT DATE: TIME:
THIRD PARTY PAYOR: CLAIM #:

IMPORTANT:   *48 HOUR NOTICE IS REQUIRED FOR CANCELLATION

*PLEASE BRING YOUR HEALTH CARD AND THIS REQUISITION FORM

NUCLEAR CARDIOLOGY

MYOCARDIAL PERFUSION (CARDIOLOITE SESTAMIBI)

1.  EXERCISE
2.  PERSANTINE
81. DOBUTAMINE

VENTRICULAR FUNCTION (MUGA)


5.  REST
82. DOBUTAMINE

VIABILITY STUDY (THALLIUM)

69. REST

NOTE: Please inform patient regarding the discontinuation of Beta Blockers, Calcium Blockers and erectile dysfunction medications 48 hours prior to test.
CARDIOLOGY
7.  EXERCISE TEST ONLY (GXT) 9.   24Hrs HOLTER MONITOR 11.  ECHOCARDIOGRAPHY
8.  AMBULATORY BLOOD 10. 48 Hrs HOLTER MONITOR 155. STRESS ECHO
PRESSURE MONITOR 88. LOOP/CARDIAC EVENT MONITOR 174. CAROTID ULTRASOUND (Mississauga location only)
NUCLEAR MEDICINE

CNS

12. CEREBRAL PERFUSION
SCAN (SPECT)

GI

14. LIVER/SPLEEN SCAN
15. LABELLED RED BLOOD
CELL LIVER SCAN

16. GASTRIC EMPTYING
STUDY
17. ESOPHAGEAL TRANSIT
STUDY
18. SALIVARY SCAN
19. BILIARY SCAN

RESPIRATORY

20. VENTILATION/PERFUSION
LUNG SCAN

GENITOURINARY

23. RENAL SCAN
24. RENAL SCAN WITH LASIX
25. RENAL CORTEX SCAN
26. RENAL SCAN WITH
CARTOPRIL

BONE SCAN

27. TOTAL BODY
28. SPECIFIC SITES:

LABELLED
WHITE BLOOD
CELL SCAN

31. TOTAL BODY
32. SPECIFIC SITES:

MISCELLANEOUS

33. THYROID
(at the Mississauga location only)

33. PARATHYROID
(at the Mississauga location only)

33. OTHER:

REASON FOR TEST REFERRING PHYSICIAN INFORMATION
Referring Physician Signature

Referring Physician Stamp

CC Physician
Subject:  
.