Private Imaging Request

Radiology Appointments: 9342 7038 Private Medical Centre Nuclear Medicine Appointments: 9342 7480 The Royal Accounts: 9342 7028 Royal Parade Parkville Vic 3050 Facsimile: 9342 7482 (location map & patient information over page) Private Imaging Website: www.mh.org.au/Radiology Patient Details

Surname: Given Name: Date of Birth: Phone Number: Mobile: Address: Male Female UR Number: Patient Checklist Is the patient pregnant? Yes No Is the patient on Metformin? Yes No Is the patient diabetic? Yes No Does the patient have renal disease? Yes No Has the patient had a past reaction/allergy to contrast? Yes No Does the patient require an interpreter (to be organised by patient/carer)? Yes No

eGFR for Angio & CT cases involving I.V. contrast: eGFR: Date of test:

Investigations Being Requested (Please use dedicated referral for MRI & Nuclear Medicine) XRay Ultrasound Mammography Mammography +/Ultrasound CT CT Coronary Angiography Angiography Fluoroscopy OPG Examinations Requested

Preferred Date/Month of Examination

Next available or Month/Year: Clinical Details

Report and Image Requirements (only complete if different to default requirements setup for referrer) Report Fax Email Deliver Phone Report & Films return with patient Copy of report to: Image Requirements Film CD Online via PACS Please contact our Imaging Customer Liaison Officer on 0437 852 032 to discuss available report and image options and setting up a customised default setup. Referring Doctor Details

Name: Provider No: Date: Address: Telephone: Fax: Signature: Radiology use Only MIT Initials/Comments Examination Protocol: Contrast Order Date of referral: Agent: Omnipaque Other Volume (mls): Rate (mls/s): Signed: Print Name: Contrast Administration Administered by: Checked by:

RMH Private Imaging A4 Referral.indd 1 12/7/10 1:09:00 PM Private Imaging

Appointment Details

Date: Time: Please bring the following to your appointment: ➢ Medicare, DVA or current concession card ➢ Previous x-rays and scans (films or CDs) for comparison

Preparation Instructions for Patients

Please advise us if you are diabetic when making a booking. Continue to take your medications as usual unless advised otherwise. Certain procedures may require preparation. Detailed preparation instructions will be provided at the time of making an appointment.

Instruction Notes

The Royal Melbourne Hospital City Campus Site Map Melway Ref. 2B A7, B7 Private Imaging Public Car Park

Entrance to RMH Ground Floor of the N � underground public car park Private Consulting

� R Suites / Private Hospital � oyal Pde Phone 9342 7038

Royal Women’s Ser Hospital ��� vice R Tram route 19 to City Serv

� oad stop no. 10 Flemingtonice Rd Ro � ad � � Public Radiology Grattan St Department

Tram route 55, 59 To City Tram route 19 Level 1, The Royal Melbourne stop no. 14 stop no. 10 Private Hospital

Main entrance � � ED Radiology Department Enquiries Private medical rooms/private hospital � � Ground Floor, The Royal � Lifts to wards � Retail precinct Melbourne Hospital � Café � Building � Pharmacy � Function Centre

Tram stop Bus stop Taxi rank

RMH Private Imaging A4 Referral.indd 2 12/7/10 1:09:01 PM Private Imaging

REFERRAL PAD ORDER FORM

FAX TO: (03) 9342 8369 OR

CONTACT: MARY LAMBERT 0437 852 032

Please send me new referral pad(s)

Drs Name: Provider No. Address:

RMH Private Imaging A4 Referral.indd 3 12/7/10 1:09:02 PM