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IMAGING REQUEST

Appointment Time: Day: Date: Location:

PA
TI

EN
T 

D
ET

AI
LS Name:   Interpreter        Language: DOB:

Address: Patient type:             Medicare eligible         MVA

  Work injury         DVA             Non-Medicare
Gender:     Male         Female   
                Unspecified

Patient election:       Private        Public Telephone No:
UR No:  
(if relevant) 

Outpatient Clinic: 
(if relevant) Medicare No:

EXAMINATION REQUEST

CL
IN

IC
AL

 D
ET

AI
LS

  CT Angiogram - I have discussed this case with a specialist or consultant physician

  U/S guided cannulation

Creatinine:                           mols/L  (Date                        ) eGFR:                      mL/min  (Date:                          )

Previous contrast reaction: Known allergies:

Possibility of pregnancy:    Yes     No Date of LMP: Breastfeeding:    Yes     No

  MRSA / VRE        Diabetes      Other relevant considerations / alerts: 

REFERRING CLINICIAN

CO
PY

 O
F 

R
EP

O
RT

 T
O Name:   NPH (Not for Public Health System Distribution)

  Do not send reports to My Health RecordName

Address Address: RESULTS

Pager / DECT No   Fax No:
  Medinexus 
  Films / Images

  Hardcopy report to referrer
  Date required:Provider no

Telephone No 
(for any urgent/ unexpected results)

DOCTORS SIGNATURE       Date:

 (S
AM

I.6
-2

0.
01

)



DIRECTORY OF SERVICES 
SOUTH AUSTRALIA MEDICAL IMAGING
Please note hours of operation vary across sites and some services may be available on weekends at selected sites.  
Not all sites offer the full range of examinations for each service and you may be directed to another site when making your booking.

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REGION SITE NAME AND ADDRESS TELEPHONE FAX

CENTRAL Royal Adelaide Hospital Medical Imaging Level 3C (Ground), 1 Port Road, Adelaide (08) 7074 4020 (08) 7074 6136                  
Royal Adelaide Hospital Nuclear Medicine Level 2, Lift E - 1 Port Road, Adelaide 1300 724 319 (08) 7074 6122          
Women s and Children s Hospital Medical Imaging Level 2, Rogerson  
and Queen Victoria Buildings, 72 King William Rd, North Adelaide (08) 8161 6055 (08) 8161 6333                      

NORTH Lyell McEwin Hospital Medical Imaging 120   130 Haydown Rd, Elizabeth Vale (08) 8182 9999 (08) 8182 9998                  
Lyell McEwin Hospital Nuclear Medicine 120   130 Haydown Rd, Elizabeth Vale (08) 8182 9992 (08) 8282 1395      

SOUTH Flinders Medical Centre Medical Imaging Level 2 &amp; Level 3, Flinders Drive, Bedford Park (08) 7117 2555 (08) 8204 6193                          
Repat Health Precinct Medical Imaging 216 Daws Road, Daw Park (08) 7117 2500 (08) 7117 2525            

WEST The Queen Elizabeth Hospital Medical Imaging  
Ground Floor, Main Building, 28 Woodville Road, Woodville South (08) 8222 6894 (08) 8222 6040                  

QE Specialist Centre Unit 2, 35 Woodville Rd, Woodville South (opposite TQEH) (08) 8222 6565 (08) 8222 6585          
The Queen Elizabeth Hospital Nuclear Medicine  
Level 3, Area A, Main Building, 28 Woodville Road, Woodville South (08) 8222 6431 (08) 8222 6038      

COUNTRY Murray Bridge Soldiers  Memorial Hospital 96 Swanport Road, Murray Bridge (08) 8535 6740 (08) 8535 6741            
Port Pirie Hospital The Terrace and Alexander Street, Port Pirie (08) 8638 4519 (08) 8638 4368              
Riverland General Hospital 10 Maddern Street, Berri (08) 8580 2430 (08) 8580 2440              
Clare Hospital 47 Farrell Flat Road, Clare (08) 8842 6512 (08) 8842 3541    

Please bring this request form, your Medicare card and any relevant previous films/results to your appointment. There is no out of pocket expense for Medicare eligible patients. 
Your doctor has recommended that you use a South Australia Medical Imaging site for your imaging examination. You may take this request to another diagnostic imaging provider however it is important to discuss this with your doctor first.

Patient preparation  
and instructions
If you are taking one or more of the 
medications listed below, please 
inform our staff of this when booking 
your appointment: Aspirin (Astrix, 
Spren, Cardiprin, Cartia, Aspro, Disprin, 
Solprin, Asasantin, CoPlavix, DuoCover), 
Warfarin (Coumadin, Marevan), 
Dabigatran (Pradaxa), Clopidogrel 
(Piax, Plavicor, Clovix, Iscover, Plavix, 
CoPlavix, DuoCover), Prasugrel (Effient), 
Ticlopidine (Tilodene), Apixaban 
(Eliquis), Rivaroxaban (Xarelto), 
Dipyridamole (Persantin), Ticagrelor 
(Brilinta) Enoxaparin (Clexane), 
Dalteparin (Fragmin), Beta Blockers.

ANGIOGRAPHY &amp;  
INTERVENTIONAL PROCEDURES 
Procedure details will be explained  
when making an appointment.

BARIUM SWALLOW / MEAL / FOLLOW-
THROUGH (SMALL BOWEL SERIES)
Nothing to eat or drink for 6 hours before  
your appointment. Note, examination may  
take several hours to complete.

CT SCAN   ABDOMEN AND PELVIS
Procedure details will be explained when 
making your appointment. You may be  
required to not eat or drink for a set time  
before your examination. Examination may  
also require an oral preparation to be drunk.

CT SCAN   CORONARY  
ANGIOGRAM &amp; CALCIUM SCORING
Follow referring doctors instructions in  
regards to beta-blockers if prescribed.  
Avoid physical activity, smoking and drinks 
containing caffeine for at least 24 hours 
prior to your appointment. Follow any further 
instructions at the time of booking.

CT SCAN   SPINE, SINUSES,  
FACIAL BONES INCLUDING DENTAL
No preparation required. Please remove 
jewellery and piercings.

CT SCAN   ALL OTHER REGIONS 
Follow instructions given at the time of  
booking. You may be required to not eat or 
drink for a set time before your examination. 

MAMMOGRAM
Wear a two piece outfit and do not use  
talcum powder or deodorant.

MRI 
Procedure details will be explained when  
making an appointment.

NUCLEAR MEDICINE
Procedure details will be explained when  
making an appointment.

ULTRASOUND SCAN   UPPER ABDOMEN 
(INCLUDING AORTA, GALLBLADDER,  
DUPLEX RENAL, DUPLEX ABDOMEN)
Nothing to eat or drink for 6 hours prior to your 
appointment. If medication is required, a small 
amount of water is permitted. No chewing  
gum or cigarettes on day of appointment.

ULTRASOUND SCAN    
RENAL (KIDNEYS) OR PELVIC
Full bladder required. Drink 1 litre of water 
based fluid, finishing 1 hour before your 
appointment. Do not empty your bladder.

ULTRASOUND SCAN   OBSTETRIC
Full bladder required. Drink 500ml of water  
based fluid, finishing 1 hour before your 
appointment. Do not empty your bladder.

ULTRASOUND   PAEDIATRICS 
Specific instructions will be given at time  
of booking. 

Patient preparation details will be confirmed at the time of making an appointment. sahealth.sa.gov.au/sami


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