IMAGING REQUEST |

IMAGING REQUEST
Dr Frank Burke | Dr Cheryl Bass | Dr Andrew Rotstein
316 Malvern Road, Prahran 3181
T: 9529 7333 F: 9529 7833 E: [email protected]
vhmi.com.au
Patient Details
Imaging Request
Clinical Notes
Referring Doctor
Doctor’s Signature:
Private
Images via MIA Direct
WC
Films to return with patient
Pension
Phone report (No
TAC
Fax report (No
Vet. Aff.
Copies to
)
)
Date:
3T MRI +/– Orbits +/– Skull +/– Chest X-ray
CT Scanning
IMPORTANT: Indicate whether the following applies to your patient.
For Diabetic patients on Metformin and all patients over 60 years
History of welding, grinding, sheet metal work
Yes
No
What is current renal function?.....................................................................
Cardiac pacemaker
Yes
No
Date of renal function?..................................................................................
Brain aneurysm clip
Yes
No
Cochlear implant
Yes
No
Sex: Male
Female
Is the patient pregnant? Yes
No
Location
Your doctor has recommended that you use Victoria House
Medical Imaging. You may choose another provider but please
discuss this with your doctor first.
TOORAK
Instructions
South Yarra
STREET
LT CHAPEL ST
Prahan
PRINCE
ROAD
ELL RO
AD
ROAD
CROMW
ROAD
STREET
WILLIAM
BANGS
ST
S
S ST
HIGH
N
316
Hawksburn
CHAPEL
Victoria House Imaging Pty. Ltd.
ACN 073 325 087 ABN 80 643 315 684
N ST
MALVERN
tal
GREVILLE
WILSO
SURREY
Alfred Hospi
PLEASE BRING YOUR MEDICARE CARD AND HEALTHCARE
CARD OR WORKCOVER/T.A.C. CLAIM NUMBER.
ANY PREVIOUS X-RAYS ARE ALSO REQUIRED.
ROAD
EN ST
BENDIGO
ST
AL
PUNT
BARIUM MEAL AND/OR SWALLOW
Nothing to eat or drink for 6 hours before examination.
COMMERCI
ROAD
NUCLEAR MEDICINE
CT SCAN
3T MRI
Instructions will be given over the phone at the time of booking.
Jam
Factory
GARD
ESSEX ST
ULTRASOUND – RENAL
A full bladder is required.
STREET
ROAD
ST. KILDA
ULTRASOUND – UPPER ABDOMEN
Nothing to eat or drink and no smoking for 6 hours before
examination.
CROMWELL
ROAD
ROAD
vhmi.com.au
Onsite parking available and where indicated
Victoria House Medical Imaging
is a member practice of MIA Radiology
Melway
Reference
Map 58 E5
Tram No. 72
Stop 32
Bus No.
216/219/220
Stop 16