EastMed Integrated Medical Centre

EastMed Integrated Medical Centre
188 St Heliers Bay Rd, St Heliers
Tel.: (09) 585 0534
Fax (09) 585 0533
e-mail: [email protected]
www.eastmedradiology.co.nz
Patient Details
Surname
Mr
Mrs
Miss
Ms
First Name
Dr
Date of Birth
NHI#
ACC#
Address
Phone
INS#
X-RAY
Chest
Ultrasound
Spine
Musculoskeletal
Obstetrics
Other
Musculoskeletal
Vascular
Abdomen
Testes
Dating
Shoulder
Hip
Aorta
Renal
Hernia
Nuchal
Elbow
Knee
Carotid
Pelvis
Thyroid
Anatomy
Wrist
Ankle
DVT
Growth
Injection
Other (specify)
Other (specify)
Clinical Details
LMP:
EDD from scan:
Code:
Referrer Details
Name
(please print)
Signature:
Phone report to:
Copy to:
(___)_________
Fax report to:
NZMC/NZONC #
Date:
/
/
(___)_________
No charge for ACC, dating and 3rd trimester pregnancy scans
EastMed Integrated Medical Centre
188 St Heliers Bay Rd, St Heliers
Tel.: (09) 585 0534
Fax (09) 585 0533
e-mail: [email protected]
www.eastmedradiology.co.nz
Patient Preparation
Abdomen - N
othing to eat or drink for 4 hours before
the scan. You can take your medication
with small amount of water.
Pelvis -E
mpty your bladder and drink rapidly
1 litre of water. Finish drinking 1 hour
before your appointment.
Pregnancy- For early pregnancy up to 16weeks fill
your bladder as for pelvic scan (above)
Over 16weeks no preparation.
All other scans
No special preparation
X-Ray
No preparation
Clinical Indication Code
TA
EP
UD
BA
CT
NT
NF
AN
AF
Threatened abortion
Suspected ectopic pregnancy
Uterus not equal to dates (more than 4 weeks)
Dating scan
Consideration of termination
Nuchal Translucency (12 weeks)
Nuchal Translucency follow-up
Anatomy (20 weeks)
Anatomy follow-up
GR
GF
PL
AH
AP
MP
FC
FD
PP
Suspected Growth Abnormality
Suspected Growth Abnormality follow-up
Check placenta
Antepartum haemorrhage
Abdominal pain
Malpresentation (after 36 weeks)
Suspected fetal compromise
Suspected intrauterine fetal demise
Maternal Postpartum