Health Care Information Sheets & Forms

Preparing for Your Procedure

At PSFDH, we want to ensure you have the information you need to ensure the best possible outcomes for your care. Below are Health Care Information Sheets on a variety of services and procedures offered at the hospital.

 

If you have additional questions, please speak with your health care provider.

Patient and Family Information Guide 

Diagnostic Imaging

• Pocket Health - Download details on how you can access your imaging records
• Xray Requisition (June 2019)
•  Cardiac Testing Requisition
•  Pulmonary Requisition
• CT Scan Requisition
• Ultrasound Requisition
• Patient Information Sheet – Ultrasound Preparation Instructions
• Patient Information – Abdomen and Pelvis Ultrasound
• Patient Information Sheet – Abdomen Ultrasound
• Patient Information Sheet – Barium Enema
• Patient – Information – Bone Mineral Density
• Patient Info Sheet – Echocardiogram
• Patient Information Sheet – CT Scan
• Patient Information Sheet – Carotid Doppler Ultrasound
• Patient Information Sheet – Mammogram
• Patient Information Sheet - Medical Day Unit Blood Product Order Set
• Patient Information Sheet -Obstetrical Ultrasound
• Patient Information Sheet – X-Rays, Pregnancy and you
• Patient Information – Pelvis Ultrasound
• Patient Information Sheet – Small Bowel – Follow Through
• Patient Information – Upper GI Series or Barium Swallow
• Patient Information Sheet – Radiology IV Contrast – Discharge Instruction

Day Hospital (Out-Patient/Rehab)  

• Referral Form  

Lanark County Sexual Assault & Domestic Violence Program

• Referral Form 

Medical Day Clinic (GWM/Perth Site)

• Process for Accessing Medical Day Care Unit
• Medical Day Unit Referral Form
• Laboratory Requisition

      Blood Transfusion Forms

• Consent to Receive Blood Component
  
• Medical Day Unit Blood Product Order Set
• Pamphlet - About Blood Transfusions
• Pamphlet - Going Home After A Blood Transfusion

       Iron

• Venofer Patient Information
• Intravenous Iron Replacement (Adult Order) Set 

      IVIG

• IVIG Patient Information
• Ministry - IV Request Form (Neurology Use only)
• MOH IVIG Request Form - Non-Neurology Patients

• Therapeutic Phlebotomy Order Set