Northtowns Imaging - CATs1000 Youngs Road, Suite #106 Williamsville, NY 14221 Phone 716-689-4406 Fax 716-689-1791 Paula Fagley pfagley@insighthealth.com |
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Head |
Trauma Routine No Contrast |
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Soft Tissue Neck |
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Chest |
Standard High Resolution |
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CT Arthogram |
Shoulder Knee |
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Spine |
Cervical Thoracic/Levels Lumbar |
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Pelvis |
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Abdomen |
No Contrast With Contrast |
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Total Body Screening |
Head, Chest, Abdomen & Pelvis |
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Other - Specify |
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*PLEASE SPECIFY IF CONTRAST IS DESIRED*
Patient Name:
Patient Date of Birth:
Phone Number:
Referring Physician:
Physician Phone: Fax:
Diagnosis/Clinical History:
VIP Docs Inc. 5500 North Service Road - The Penthouse Burlington, Ontario Canada L7L 6W6
Phone (416) 907-1065 Fax (416) 907-5822 www.vipdocs.com info@vipdocs.com