The Canberra Hospital
Your Reference:
Medical Imaging
Request
Patient Surname
Given Name
Gender
Date of Birth
Address:
Post Code:
Medicare Card Number:
Tel (home)
Tel (business)
Mobile
Does the patient have a history of renal disease? Yes
If YES then all CT and MRI requests must detail a recent Creatinine and eGFR (see below)
Examination requested:enter requested info
Clinical Notes:enter clinical notes
Creatinine level:-
Date taken:-
eGFR level:-
Date taken:-
Patient is Diabetic
Patient is taking Metformin
Patient is Pregnant
Patient is breast feeding
Allergies:
None recorded.
Veteran Affairs/Work Cover/Other cover details
Doctors Signature & Request date
/ No Insurance /
Copy to details...
Referring Doctor (Provider number, Name, Address, Tel no, Fax no)
Dr. A. Practitioner 2426621B 13 Best St.
PILL LAND SA 5000 02 9908 4888 02 9953 0276
Appointment Details (Patients: When booking, please record details here)
Time: .................................................................................................
SPECIAL INSTRUCTIONS: ....................................................................
Date: .................................................................................................
...........................................................................................................
**Please Note**
General X-Ray and OPG services do not require an appointment between 08:00am and 16:30pm Monday to Friday
For all other services an appointment will not be made until the referral is received by the Medical Imaging Department
The Canberra Hospital
Medical Imaging Diagnostics & Treatment Building 12, Level 2
Open Monday – Friday 8:00 – 4:30pm
Phone: (02) 6244 2159 Fax: (02) 6244 2494
Closed Public Holidays
Please bring all previous films and/or images at the time of appointment
Services Provided at Canberra Hospital Imaging Department
Angiography and
peripheral interventions
Bone Mineral Density
CT and CT
angiograms
Fine Needle Biopsy
under U/S or CT
guidance
General Xray
Long Films
Mammography
Diagnostic only
MRI
Musculoskeletal
Injections
( U/S or CT guided)
Nuclear Medicine
OPG
SPECT and PETCT
Ultrasound Breast
Ultrasound General
(Not antenatal screening)
Screening procedures
Ultrasound Vascular
Studies includingDVTs
Carotids and renal
The majority of procedures are covered by Medicare and are bulk billed
Please contact us on (02) 6244 2159 if you have any concerns