VIP Docs Inc. Physician Referral Form

Northtowns Imaging - CATs

1000 Youngs Road, Suite #106

Williamsville, NY 14221

Phone 1-866-7MRINOW Fax 716-689-1791

Head	Trauma Routine No Contrast
Soft Tissue Neck
Chest	Standard High Resolution
CT Arthogram	Shoulder Knee
Spine	Cervical Thoracic/Levels Lumbar
Pelvis
Abdomen	No Contrast With Contrast
Total Body Screening	Head, Chest, Abdomen & Pelvis
Other - Specify

*PLEASE SPECIFY IF CONTRAST IS DESIRED*

Patient Name:

Patient Date of Birth:

Phone Number:

Referring Physician:

Physician Phone: Fax:

Diagnosis/Clinical History:

VIP Docs Inc. 5500 North Service Road - The Penthouse Burlington, Ontario Canada L7L 6W6