L excellence au Rendez Vous! www.radimed.ca TÉTE ET COU

1 Westmount Square, Suite C210
Westmount, Qc H3Z 2P9
Tél.: 514 939-9764
Fax.: 514 939-9363
215 Frobisher, Pointe-Claire, Qc H9R 4R9
Tél.: 514 697-9940 - Radiologie
Fax.: 514 697-3711
Tél.: 514 697-8855 - IRM
Fax.: 514 697-8854
6363 route Transcanadienne
Saint-Laurent, Qc H4T 1Z9
Tél.: 514 747-8192
Fax.: 514 747-8184
600 Boul. Harwood
Vaudreuil-Dorion, Qc J7V 6A3
Tél.: 450 218-6111
Fax.: 450 218-7111
Lé
Name & surname
Legend - Exams available at
Phone number
Date of birth
Clinical information (mandatory)
Crâne / Skull
Sinus / Sinuses
Massif facial / Facial bones
Mastoïdes / Mastoids
Nez / Nose
Tissus mous cou / Neck soft tissues
Maxillaire inférieur / Mandible
Orbites / Orbits
Art. Temporo-mandibulaires / TMJ
Poumons / Chest
Hémithorax / Ribs
Sternum
Abdomen plaque simple / KUB
Abdomen incidences multiples /
Art. Acromio-claviculaires / ACJ
Art. Sterno-claviculaires / SCJ
Clavicule / Clavicle
Omoplate / Scapula
Épaule / Shoulder
Humérus / Humerus
Coude / Elbow
Poignet / Wrist
Main / Hand
Doigt / Finger
1 2 3 4 5
G/L D/R
Abdominal series
Cervicale / Cervical
Dorsale / Thoracic
Lombo-sacrée / Lumbo-sacral
Sacrum
Coccyx
Art. Sacro-Illiaques / SIJ
Série scoliotique / Scoliosis series
G/L D/R
G/L D/R
G/L D/R
G/L D/R
G/L D/R
G/L D/R
G/L D/R
> 9 ans non couvert par la RAMQ
> 9 years not covered by Medicare
G/L D/R
Diagnostique / Diagnostic
*Dépistage / Screening
Agrandissement /
Compression / Spot compression
G/L D/R
G/L D/R
G/L D/R
G/L D/R
G/L D/R
*Centre accrédité PQDCS / Accredited Center
G/L D/R
1
2
3
4
5
G/L D/R
Projections station debout /
Weight bearing views
Mesure membres inférieurs
(projection couchée seulement) /
Étude métastatique / Metastatic surv.
Étude rhumatique / Arthritic surv.
Étude métabolique / Metabolic surv.
Ordering Physician
Bassin / Pelvis
Hanche / Hip
Fémur / Femur
Genou / Knee
Rotule / Patella
Jambe / Leg
Cheville / Ankle
Pied / Foot
Orteil / Toe
Talon / Heel
G/L D/R
Gorgée barytée / Barium Swallow
Repas baryté / Upper G.I.
Grêle / Small Bowel Series (SBFT)
Lavement baryté / Barium Enema
Lower limbs length measurement (non
weight bearing)
[Nom en lettres moulées / Print name]
License N°
Final report in English
Stationnement gratuit sur place / Free Parking on site
No deodorant, antiperspirant, powder or body lotion under your arms or on
your breasts.
autour des seins.
12 hours before the examination do not smoke, no liquid, no food and do
not chew gum.
Prendre 10 onces de Citromag
claire (consommé, jus (sans pulpe) jello, thé, café, pas de produits laitiers)
Drink 10oz of chilled Citromag at 4:00 p.m. the day before your exam.
Clear liquid diet as of 4:00 p.m. the day before your exam (Clear soup/
broth, juice (no pulp), jello, tea, coffee, no dairy products). As of 10:00
p.m. the night before your exam no drinking or eating, no smoking and do
not chew gum.
•
thé, café, pas de produits laitiers.
Acheter PURGODAN ou PICO-SALAX à la pharmacie. La veille de
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prenez les laxatifs.
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second dose at 2:00
p.m. Drink a lot of water to stay hydrated while
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taking laxatives.
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Liquid diet (24 hours before exam) Clear soup (broth only), juice,
jello, tea, coffee, no dairy products.
Buy PURGODAN or PICO-SALAX at a drug store. Start to drink the
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