Referral form
Mammogram requisition
A mammogram requisition asks an imaging facility to perform screening or diagnostic mammography. Provincial breast-screening programs (such as Ontario’s OBSP) and hospital diagnostic departments use different doors. Screening in an eligible asymptomatic person is not the same request as a new lump. Tick the wrong pathway and the patient waits in the wrong queue — or is billed wrong.
Screening versus diagnostic
Screening mammography is for people with no current breast complaint who meet the program’s age and risk rules. Diagnostic mammography is for a lump, focal pain, nipple discharge, skin change, or an abnormal screen that needs workup. Do not send a symptomatic patient through the screening program to “get in faster.”
Use the facility’s current form. If the person is already in a provincial screening program, a new diagnostic req should say so. If they are high-risk (gene, chest radiation, strong family history), use the high-risk pathway the province actually runs — do not invent MRI on a screening pad.
A lump is a location
Write clock-face or quadrant, size if you felt it, and how long it has been there. “Please image breasts” with a palpable mass and no side is how the technologist pages you from the booth.
Who completes it
The physician or nurse practitioner who assessed the patient (diagnostic) or who is ordering screening outside a self-refer program. Some screening programs let eligible people book without you. If you are signing a requisition, you are responsible for the indication on it.
How to complete the requisition
- Screening or diagnostic — one box.
- For diagnostic: side, site, symptom, duration. Prior imaging dates if known.
- For screening: last mammogram date, implants, whether they are in the provincial program.
- Pregnancy and lactation if the form asks. Mammography is not a first-trimester default.
- Comparison site if films live elsewhere.
- Urgency that matches a discrete finding, not anxiety alone.
- If you also want ultrasound, say why (young dense breast, palpable, cyst vs solid). Ultrasound is not a substitute sentence for “worried.”
Worked example (fictional)
Diagnostic mammogram — palpable lump, family practice
Fictional 44-year-old. Do not copy into a real imaging req.
Diagnostic, not screening. Left breast, 10 o’clock, 2 cm from nipple, 1.5 cm firm mass noticed 3 weeks, no skin change, no fever. No prior mammogram. Not pregnant. Please mammogram ± targeted ultrasound per radiology protocol. Not OBSP screening. I am the FP. Patient has the callback number on the form.
Why imaging sends it back
- Screening ticked on a symptomatic patient.
- No side or no site for a palpable finding.
- Wrong program form (diagnostic hospital pad sent to screening, or the reverse).
- Asking for MRI as a first test without the high-risk or radiologist pathway.
- Missing identifiers or an unsigned req.
Draft the mammogram requisition from the visit
In Scribeberry, open Forms, search for mammogram requisition or breast imaging, or upload the facility’s current PDF. Generate from the encounter and your notes, then review every field before you send. Scribeberry does not pre-map this form. You still review and sign. Scribeberry does not book imaging.
Frequently asked questions
Can the patient self-refer to screening?
Some provincial programs allow eligible people to book screening without a new requisition. Diagnostic imaging for a lump still needs a clinician requisition. Follow the program in your province.
Mammogram or ultrasound first?
That is a protocol decision based on age, density, and the finding. State the indication clearly so radiology can choose. Do not order both “because.”
Is this the same as an Ontario general DI requisition?
Sometimes the hospital uses one pad. Breast screening programs often use their own. Upload the PDF the facility asked for.
Does Scribeberry book the mammogram?
No. Scribeberry helps you complete the PDF. You send it to the facility. Keep a copy in the chart.
Forms
