Appointment booking: Call 519-256-4914 or fax 519-256-3221 · Please provide 24 hours advance notice if unable to keep appointment · Arrive 10 minutes early with your health card and this form.
Patient Information
Search existing patients or enter new
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Patient details — auto-filled from search or enter manually
Format: 1234-567-890 (10 digits)
Appointment time auto-updates live · Click the field to lock in the current time
Provider Information
Pre-filled from clinic profile
Send To & Patient Notification
Choose destination lab and how the patient is notified
Patient notification
SMS PREVIEW — sent to patient
Hi [Patient], your requisition from Dr. Alex Chen has been submitted to [Lab]. Ref: [REQ#]. Show this SMS or your health card at your appointment. — Requify Health
X-Ray — No Appointment Required
Walk-in · Check all required views
Ultrasound ⚠ Appointment Required
Select all required studies
Additional Studies
Bone density · Echocardiography · Breast imaging · Nuclear medicine · Vein clinic
Bone Mineral Density
Digital Breast Imaging (appointment required)
Breast Ultrasound
Vein Clinic
Echocardiography (appointment required)
Accredited by CorHealth Ontario
Nuclear Medicine (appointment required)
Please attach: Present and past medical history, list of current medications, physical findings and relevant test results and reports. All facilities are scent-free.
Provider Signature
Required to authorize this requisition