IMAGING REQUEST Dr Frank Burke | Dr Cheryl Bass | Dr Andrew Rotstein 316 Malvern Road, Prahran 3181 T: 9529 7333 F: 9529 7833 E: vichouse@i-med.com.au 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