What the R250-10-115 is for
The CT Request Form is the single requisition for CT exams at every facility in Manitoba that offers CT. The same form covers outpatient, emergency department and inpatient requests, though emergency and inpatient workflows at each site stay as they were. It replaced the older diagnostic imaging requisitions for CT, which Shared Health asks clinics to discard. MRI has its own form, and X-ray, ultrasound and nuclear medicine use separate DI requisitions.
The radiologist decides how urgent the exam is from the history you provide. The urgency box you tick is used as a second check on that judgement and doesn’t guarantee a place in the queue.
Who completes it
The ordering clinician completes every section and signs it. Clerical staff complete only the box marked for clerical use, and the imaging department completes its own section. Fields marked with an asterisk are required, and the form says plainly that missing or illegible required fields mean the request is declined and returned.
How to fill in the request
Patient information
Enter the name, date of birth, sex, PHIN and a daytime phone number, all required. For outpatients, choose first available (Winnipeg only), willing to travel within Manitoba, or a preferred site. If you leave travel unspecified, Shared Health assumes the patient will travel to a site with a shorter wait. If you’ve already spoken to a radiologist, write their last name and site above the preferred site.
Scheduling
Pick emergent, urgent or elective. Shared Health’s broad timelines are within 24 hours for emergent, 7 to 30 days for urgent, and the next available slot for elective. Use the requested exam date only for a future date that matters clinically, such as a scan after chemotherapy or an aneurysm follow-up. Record mobility, isolation needs and pregnancy status here too.
Examination request
Name the exam and list previous relevant imaging with dates and locations. The history field must never be blank. Radiologists use it to set priority and choose the protocol, so include the clinical question and any relevant surgical history.
Allergy, weight and renal risk
Answer the contrast allergy question and give the patient’s weight, which is always required. Patients over 250 lbs need a recent accurate weight, and lighter patients can have an estimate. The renal risk questions ask about known kidney disease and any prior or pending renal referral. If either answer is yes, give the most recent creatinine and eGFR with the date, or a point-of-care result where that test is available.
Ordering clinician information
Sign, print your name, and give your billing number, the date ordered and a 24-hour number for critical results. These are required. Use the copy-to line for another clinician who should receive the report.
Common reasons it’s returned
- A blank or unreadable history section.
- Missing PHIN, date of birth, weight, billing number or 24-hour critical results contact.
- An unsigned form, or a signature with no printed name.
- Renal risk questions answered yes with no creatinine result or date.
- The same requisition faxed to both Central Intake and the imaging site, which causes duplicate bookings.
Submitting and who pays
Fax requests for CT in Winnipeg to Central Intake at 204-926-3650 or 1-866-210-6119. This includes Winnipeg clinicians ordering exams outside the city. For CT outside Winnipeg, fax the nearest imaging department providing CT. The imaging site then schedules the patient. Medulla can suggest this requisition when the visit plan orders a CT.