EastMed Integrated Medical Centre 188 St Heliers Bay Rd, St Heliers Tel.: (09) 585 0534 Fax (09) 585 0533 e-mail: eastmedradiology@yahoo.co.nz 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: eastmedradiology@yahoo.co.nz 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