A4 General Request Form Barwon Medical Imaging

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PO Box 281, Geelong, Victoria 3220
APPOINTMENTS / ENQUIRIES
REQUEST FORM
T
03 4215 0300 03 4215 0447
F
.au
PATIENT DETAILS
Name
Date of Birth
/
/
Male
Female
Address
Postcode
Telephone (Home)
(Mobile)
APPOINTMENT Date
/
/
Time
UR No.
LOCATION
* FOR ANGIOGRAPHY,
EXAMINATION
CT, MRI & IVP
Please indicate eGFR if known
CT*
Ultrasound
Nuc Med
MRI
*
Angiography*
(refer below)
Date
/
/
eGFR
X-ray
OPG/Dental
Mammo + / - US
Biopsy
Intervention
Diabetic
Fluid Restrictions
REGION
CLINICAL NOTES
URGENT REPORT
Phone
MRI - ANSWERS ARE MANDATORY
CONTRAINDICATIONS:
METAL / IMPLANT ALERT:
YES / NO
Does the patient have:
YES / NO
Has the patient been a metal worker, welder,
or had an eye injury caused by metal?
1. an epicardial/cardiac pacemaker/wire?
Does the patient have any metal implant?
2. a cerebral aneurysm clip?
Does the patient have a stent?
3. a cochlear/stapes (ear) implant?
Please describe
If YES to any of the above questions,
please discuss with Radiologist.
IMAGES
REFERRER DETAILS
Name
Pager/Mobile
Web Access
CD with Patient
Signature
Date
/
/
Other
Provider No.
COPY TO
A division of

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