Patient details	
Medicare Number	
DOB	
Mobile		

Imaging request	
Consent	
Clinical notes		

Referring Doctor					

	M/C		Take Film / CD			
						
	HCC		Synapse / CD / Film  			
						
	W/C		Phone Report			
						
	TAC		Fax Report			
						
	V/A		Routine Delivery			
						
			Electronic Download			
						
			Copy to			

Referrer Signature	Date: 	

	Is there a chance you might be pregnant? n Yes ο No ο
Patient Signature........................................................................................	
ο  MRI	+/- BREAST	+/- ORBITS	+/- SKULL	+/- CHEST X-RAY
IMPORTANT: Indicate whether the following applies to your patient (please circle): History of welding, grinding, sheet metal work 	Yes / No Cardiac pacemaker 	Yes / No Brain aneurysm clip 	Yes / No Cochlear implant 	Yes / No		ο CT Scanning
If Diabetic does treatment contain Metformin?
Yes / No
What is current renal function?
__________________________________________
Date of renal function? 		

	GP MRI REBATABLE SCANS		
PATIENTS UNDER THE AGE OF SIXTEEN (16) 

HEAD
ο Unexplained seizures
ο Unexpected headache where significant pathology is suspected
ο Paranasal sinus pathology which has not responded to conservative therapy
ELBOW
Following radiographic examination where a significant fracture or avulsion injury is suspected that will change management
WRIST
Following radiographic examination where scaphoid fracture is suspected	SPINE
Following radiographic examination for any of the following:
ο  Significant trauma
ο Unexplained neck or back pain with associated neurological signs
ο Unexplained back pain where significant pathology is suspected
HIP
Following radiographic examination for any of the following:
ο Suspected septic arthritis
ο Suspected slipped capital femoral epiphysis
ο Suspected Perthes disease
KNEE
n Internal joint derangement	PATIENTS SIXTEEN (16) YEARS AND OLDER
 HEAD
ο Unexplained seizure(s)
ο Unexpected chronic headache with suspected intracranial pathology
SPINE
ο Suspected cervical radiculopathy
ο Cervical spine trauma
PATIENTS SIXTEEN (16) YEARS TO FORTY NINE (49) YEARS ONLY
KNEE
Following acute knee trauma:
ο Inability to extend the knee suggesting the possibility of acute meniscal tear
ο C linical findings suggesting acute anterior cruciate ligament tear	

	GP MRI REBATABLE SCANS		

BARIUM MEAL AND/OR SWALLOW 

Please contact St Albans for appointment and instructions.
BARIUM ENEMA
Please contact St Albans for appointment and instructions.
IVP
Please contact St Albans for appointment and instructions.
CORONARY CT ANGIOGRAM
Please contact Hawthorn, St Albans, Moonee Ponds, Footscray or Sunshine for special instructions.
CT CALCIUM SCORING
Please contact Hawthorn, St Albans, Moonee Ponds, Footscray or Sunshine for special instructions.
CT SCAN HEAD
DO NOT TAKE ANY DIABETIC TABLETS
Nothing to Eat or Drink for 2 hours before examination. Drink 1 litre of water during this time. Can go to the bathroom, no need to hold bladder. 
CT SCAN CHEST
DO NOT TAKE ANY DIABETIC TABLETS
Nothing to Eat or Drink for 2 hours before examination. Drink 1 litre of water during this time. Can go to the bathroom, no need to hold bladder. 
CT SCAN ABDOMEN & PELVIC
DO NOT TAKE ANY DIABETIC TABLETS
Nothing to Eat or Drink for 2 hours before examination. Drink 1 litre of water during this time. Can go to the bathroom, no need to hold bladder. Please call clinic for further instructions.
CT SCAN IVC
DO NOT TAKE ANY DIABETIC TABLETS
Nothing to Eat or Drink for 2 hours before examination and come in 1 hour before appointment time for the injection. UPPER ABDOMINAL ULTRASOUND
Nothing to Eat or Drink for 6 hours before examination. Oral medication permitted.
	
RENAL ARTERY DOPPLER ULTRASOUND
Nothing to Eat or Drink for 6 hours before examination. Oral medication permitted.
MALE/FEMALE PELVIC ULTRASOUND
Empty bladder 1 hour before examination and then drink one litre of water. Arrive with a comfortably full bladder. OBSTETRIC/LESS THAT 12 WEEKS ULTRASOUND
Empty bladder 1 hour before examination and then drink one litre of water. Arrive with a comfortably full bladder. MAMMOGRAPHY & BREAST ULTRASOUND
No powder or underarm deodorant to be used and please bring previous mammography or ultrasound films with you on day of examination.
ECHOCARDIOGRAPHY (BULK BILLED)
Available for Paediatric and Adult patients.
STRESS ECHOCARDIOGRAM (BULK BILLED)
Available at Hawthorn, St Albans, Moonee Ponds or Sunshine.
MRI
MRI does not use any radiation. Images can be obtained from any part of the body, and can be seen from any angle without altering the patient’s position. This maximizes the comfort of the patient. Breast MRI used in early detection of breast cancer for women in high-risk groups.
NUCLEAR MEDICINE (BULK BILLED)
Please contact St Albans for appointment and instructions.