Diagnostic Requisitions
Diagnostic Requisitions – Health Practitioners Only
This page is designed to allow physicians and nurse practitioners electronic access to our most current Diagnostic Imaging requisitions. These requisition forms are for physicians and nurse practitioners to complete only. They are not intended for patients to complete.
*Please note: Wait times for CT and MRI, in particular, are longer than usual due to high demand and significant staffing shortages. The hospital assigns a priority level based on the clinical information provided. Those requiring non-urgent procedures are most impacted by lengthy wait times.
Refer to the provincial wait times information to see if your patient can receive a CT or MRI faster at a neighbouring hospital or imaging centre, provided the patient is agreeable to travel for the test (e.g. Kingston, Napanee or Peterborough).
Please fax all completed requisitions to 613-969-5561.
- Bone Mineral Density Requisition
- Breast MRI requisition
- Cardiopulmonary Requisition
- CT Requisition (please also fax back Consent to Treatment form if required for the specific procedure)
- CT Cardiac requisition
- CT Colonography Requisition
- External Imaging Consult
- Interventional Radiology Requisition (please also fax back Consent to Treatment form if required for the specific procedure)
- Mammography Requisition
- MRI Requisition
- Nuclear Cardiology Requisition
- Nuclear Medicine Requisition
- Ultrasound
- Ultrasound (Obstetrical)
- X-Ray Requisition
No Diagnostic Imaging exam will be performed at any Quinte Health hospital without a fully completed requisition signed by a licensed physician or nurse practitioner. Any requisition that appears fraudulent will be investigated immediately and imaging services will not be provided.