Requisition
Download the Merivale Medical Imaging requisition form. A valid, completed requisition from a licensed physician is required for all scheduled imaging services.
Completing the Requisition
A valid, fully completed requisition from a licensed physician or healthcare provider is required for all scheduled imaging services at Merivale Medical Imaging. Follow the steps below before submitting a referral.
Complete All Patient Information
Include the patient’s full name, date of birth, health card number, and contact information. Incomplete requisitions may delay booking or be returned.
Provide Clinical Indication
Include a clear clinical indication and relevant patient history. This supports appropriate protocol selection and triage by our radiology team.
Sign & Include Physician Information
All requisitions must include the referring physician’s CPSO number, clinic address, phone, and fax number. Unsigned or incomplete physician information cannot be accepted.
