* required "*" indicates required fields First Name*Last Name*Email* Phone*I wish to:* Book an appointment Cancel an appointment Type of exam* Ultrasound Pain Management X-Ray Mammography Paediatric (Kids) Imaging Please select the type(s) of exam you wish to book or cancelUpload your requisition*Accepted file types: pdf, jpg, png, Max. file size: 5 MB.Max. 5MB filesize We are unable to book your appointment without a requisition form signed by your doctor. Please have your doctor’s office fax a copy to 1.587.316.0834, or upload a copy here. *By uploading your requisition form you are giving Shift Imaging consent to collect this information under Part 3 of the Health Information Act.Consent* I agree to the privacy policy. *Please view our privacy policy here.Human?*Calculate twelve times threeThis form is protected with Google reCAPTCHA.PrivacyTermsNameThis field is for validation purposes and should be left unchanged.