FILLABLE REQUISITION FORM

X-ray

No Appointment Needed (Please call to confirm spot availability)

Ultrasound Examinations

Call For Appointment

Please bring your health card and this requisition with you and arrive 15 minutes before your appointment for registration. Late arrival may require re-booking. Missed appointments will be subject to a $50 fee. At least 24-hour cancellation notice is required. PLENTY OF FREE PARKING

This requisition form can be taken to any licensed facility providing healthcare services including hospitals and ICHSCs, such as those listed on the ICHSC Program website: https://www.ontario.ca/page/community-surgical-and-diagnostic-centres