LXA Requisitions
Please note that we are an active Ocean eReferral site and all of our requisitions are available for ease of referral within Ocean or your EMR, if you are also an Ocean user.
PDF (only) Versions: All forms now include our new clinic at 3209 Wonderland Road, South.
NOTE: To request hardcopy/paper pads of any of these requisitions, please email your request to
- General Imaging Requisition [PDF] (Rev. 090124)
- Ultrasound and Echocardiogram Requisition [PDF] (Rev. 130723)
- Obstetrical Ultrasound - MFM Requisition [PDF] (Rev. 130723)
- OBSP Appointment Date and Time Card [PDF]
- Patient Auth for Release of Information - InteleConnect
- MSK Requisition [PDF] (Rev. 130723)
- We do prefer the use of Ocean to submit your MSK eReferral submissions as you have the option to include all relevant CPP [Cumulative Patient Profile] data for your patient. If you choose to submit an MSK referral via an EMR form (not Ocean eReferral), or hardcopy (LXA MSK requisition or via the provided fillable PDF above), please ensure that you are also including (attaching) all relevant patient history.
Telus PS Suite Form Versions: All forms now include our new clinic at 3209 Wonderland Road, South.
Please look for our published forms within PS Suite, under 'DI - London X-Ray'.
- DI - London X-Ray Associates - General Diagnostic Imaging - Jan 2024 [CFM] (Rev. 090124)
- DI - London X-Ray Associates - Ultrasound & Echocardiograms - July 2023 [CFM] (Rev. 130723)
- DI - London X-Ray Associates - Obstetrical Ultrasound Clinic - July 2023 [CFM] (Rev. 130723)
- DI - London X-Ray Associates - MSK Injections Program July 2023 [CFM] (Rev. 130723)
If you would like to manually download and import one or more of these CFM files, click the links above.
- Information on how to import custom forms into PS Suite can be found here. PS Suite EMR: Importing Custom Forms
MSK: We do prefer the use of Ocean to submit your MSK eReferral submissions as you have the option to include all relevant CPP [Cumulative Patient Profile] data for your patient. If you choose to submit an MSK referral via an EMR form (not Ocean eReferral), or hardcopy (LXA MSK requisition or via the provided fillable PDF above), please ensure that you are also including (attaching) all relevant patient history.
Accuro Versions: All forms now include our new clinic at 3209 Wonderland Road, South.
Please look for our published forms within Accuro. The forms are published as follows:
- London X-Ray General Diagnostic Imaging (Rev. 090124)
- London X-Ray Ultrasound and Echocardiograms (Rev. 130723)
- London X-Ray Obstetrical Ultrasound and Maternal Fetal Medicine Clinic (Rev. 130723)
- London X-Ray MSK Injection Program (Rev. 130723)
MSK: We do prefer the use of Ocean to submit your MSK eReferral submissions as you have the option to include all relevant CPP [Cumulative Patient Profile] data for your patient. If you choose to submit an MSK referral via an EMR form (not Ocean eReferral), or hardcopy (LXA MSK requisition or via the provided fillable PDF above), please ensure that you are also including (attaching) all relevant patient history.