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Ultrasound Requisition and Forms

How can I refer a patient to the Clinique d’échographie de l’Outaouais?

  1. Talk to your patient about the ultrasound examination you would like him or her to undergo.
  2. Inform him or her of the option of having the ultrasound examination done in a private clinic. Explain to him or her that ultrasounds done in a private clinic are not covered by the Régie de l’assurance maladie du Québec (RAMQ). Fees must be paid, but could be reimbursed in full or in part if he or she is covered by a personal or group medical insurance plan.
  3. Fill out an ultrasound requisition form and give it to your patient along with our contact information so that he or she can make an appointment. You can also fax us the requisition form, but your patient is responsible for contacting us and reserving his or her appointment.

Note: We accept ultrasound requisitions from all institutions.

Ultrasound requisition form

Reminder: To be valid, a medical examination requisition must be properly completed by a doctor or midwife. The following information is required:

  • Patient’s first name, last name and date of birth;
  • Date of request;
  • Ultrasound exam(s) to be performed (clearly identified);
  • Patient’s medical history;
  • Name of the doctor or midwife who is requesting the exam;
  • The signature of the doctor or midwife or of the person authorized to sign.

Your cooperation is highly appreciated. It will greatly help your patients!

Prenatal Screening – Quebec physicians and midwives

Since November 1st 2013, the Programme Québécois de dépistage prenatal de la trisomie 21 is availbale to patients in the Outaouais region.

This program must be offered and explained to all pregnant women. If your patient wants to participate into the program, you must fill and sign form AH-611 from the ‘’Ministère de la santé et services sociaux du Québec’’ (MSSSQ), called ‘’Dépistage prénatal de la trisomie 21’’. The original form is mandatory, photocopies and faxes are NOT accepted.  You can get this form through the MSSSQ.

More information about the program

Prenatal Screening – Ontario physicians

Requisition form for blood work related to the Integrated Prenatal Screening or the First Trimester Combined Screening

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This form is provided by the Mount Sinai Hospital and must accompany the nuchal translucency ultrasound requisition.

This form is only available in English. The physician completes the patient identification sections « Test Requested » and « Clinical Information » with the patient.

Prenatal screening should only be performed once the patient has made an informed choice. Thus, it is essential to inform future parents about the options that are available to them and to explain what they are, how they work and how the results are to be interpreted.

More details