Download a requisition form for your patient's echocardiogram or caroitd ultrasound, a doctor explaining how to order an echocardiogram or carotid ultrasound.

Requisition Download

How to fill out a requisition:

  • Download the PDF by clicking on the button above and then clicking on the save button on the upper right corner of the page.
  • Complete the demographics using the first and last name, a daytime phone number, Patient’s health care number or out of province health care number, date of birth and gender of patient.
  •  Enter the reason for echocardiogram or carotid exam. Ensure to let us know if they have had any surgical procedure done i.e.: AV replacement, pacemaker as well as any symptoms the patient may be having i.e.: chest pain, shortness of breath.
  • If the patient is preoperative provide that in the history. This is to ensure there is no rescheduling prior to the procedure.
  • In the physician information block enter the ordering physician’s name, telephone number and fax number that you would like the echocardiogram report to go to including any specific clinics (for example Bone Marrow Transplant Clinic) along with the Family Physician if needed. Note: we will need the Family Physician’s address to confirm the phone/fax before sending a report.
  • Certify the exam(s) you require are checked off. Be aware that carotid exams can only be completed at our Calgary locations. Check the location of the clinic where you would like the patient booked. Please phone 403 300 6923 for hours of operation.
  • Book any exam 3 days post nuclear medicine imaging as sonographers do not wear radiation dosimeter badges.


You may now fax this in to our clinic at 403 270 3184. We will book the date and time of the exam and fax it back to your clinic.

The patient may take the requisition with him/her with the date, time, place and type of appointment.

Be aware that it is the ordering clinic’s responsibility to contact the patient with the date and time of their exam.

Make sure the patient is aware of our preparation field on the requisition. This is so they are aware to come with their health card and photo identification. They may refer to our website or phone the office at 403 270 3192 extension 3 if they have any questions.