Requisitions
Requisition forms
A signed physician requisition is required for every diagnostic imaging exam. Patients may bring a requisition in person, or referring providers may send it directly to our clinic.
Download a requisition
Print and complete the form below, then submit by fax, email or in person.
PDF requisition forms — please call 519-763-4406 if you need a form sent directly to your provider.
Don't have a requisition yet?
Please contact your family physician, walk-in clinic or referring specialist to request one. Our team is happy to answer any questions about which form is needed for your exam.
Information for referring physicians