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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 & 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 &
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 & 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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