<html>
<head>
<meta charset="UTF-8"/>
<meta name="tikaGenerated" content="true"/>
<meta name="date" content="2019-10-16T22:39:25Z"/>
<meta name="xmp:CreatorTool" content="Adobe InDesign 14.0 (Macintosh)"/>
<meta name="trapped" content="False"/>
<meta name="meta:creation-date" content="2019-10-11T06:04:02Z"/>
<meta name="created" content="Fri Oct 11 16:34:02 ACDT 2019"/>
<meta name="xmpTPg:NPages" content="2"/>
<meta name="Creation-Date" content="2019-10-11T06:04:02Z"/>
<meta name="dcterms:created" content="2019-10-11T06:04:02Z"/>
<meta name="Last-Modified" content="2019-10-16T22:39:25Z"/>
<meta name="dcterms:modified" content="2019-10-16T22:39:25Z"/>
<meta name="Last-Save-Date" content="2019-10-16T22:39:25Z"/>
<meta name="meta:save-date" content="2019-10-16T22:39:25Z"/>
<meta name="producer" content="Adobe PDF Library 15.0"/>
<meta name="modified" content="2019-10-16T22:39:25Z"/>
<meta name="Content-Type" content="application/pdf"/>
</head>
<body>
<pre>
sahealth.sa.gov.au/sami

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 REQUESTED:

BILATERAL 
BREAST  
MRI

CL
IN

IC
AL

 D
ET

AI
LS

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

Previous contrast reaction Known allergies:

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

REFERRING CLINICIAN

CO
PY

 O
F 

R
EP

O
RT

 T
O   MRSA / VRE     Diabetes    Other relevant considerations / alerts: 

Name Name:   NPH (Not for Public Health System Distribution)
  Do not send reports to My Health RecordAddress

Pager / DECT No Address: RESULTS

Provider no   Fax No:
  Medinexus

  Hardcopy report to referrer
  Date required:Telephone No 

(for any urgent/ unexpected results)

DOCTORS SIGNATURE       Date:

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.

COMPLETE TICK BOX TIMEFRAME

  REBATEABLE MRI   complete tick box    NON-REBATEABLE MRI

A Medicare benefit may be payable for this service (see Medicare Benefit Schedule).
To assist us in determining this please indicate if the following indications apply to this patient:

The patient needs to be asymptomatic and less than 50 years of age to qualify for a Medicare rebateable scan

3 or more first or second degree relatives, on the same side of the family diagnosed with breast or ovarian cancer; OR

2 or more first or second degree relatives, on the same side of the family diagnosed with breast or ovarian cancer, if any of the following applies 
to at least 1 of the relatives:
a) has been diagnosed with bilateral cancer;
b) had onset of breast cancer before 40 years of age;
c) had onset of ovarian cancer before 50 years of age;
d) has been diagnosed with breast and ovarian cancer, at the same time or at different times;
e) has Ashkenazi Jewish ancestry;
f) is a male relative who has been diagnosed with breast cancer; OR

1 first or second degree relative diagnosed with breast cancer at 45 years or younger, plus another first or second degree relative on the same side 
of the family with bone or soft tissue sarcoma at age 45 years or younger; OR       

Genetic testing has identified the presence of a high risk breast cancer gene mutation OR       

Clinically and mammographically occult cancer AND Patient diagnosed with metastatic cancer to regional lymph nodes only       

Follow-up imaging of abnormalities diagnosed on a previous breast MRI scan

IMAGING REQUEST
BILATERAL BREAST MRI

(SAMI.2-19.21) 



sahealth.sa.gov.au/sami

DIRECTORY OF SERVICES 
SOUTH AUSTRALIA MEDICAL IMAGING

X-
ra

y

De
nt

al
 / 

OP
G

Ul
tra

so
un

d

Fl
uo

ro
sc

op
y

CT M
RI

M
am

m
og

ra
ph

y

An
gi

og
ra

ph
y

In
te

rv
en

tio
na

l P
ro

ce
du

re
s

Ge
ne

ra
l N

uc
le

ar
 M

ed
ic

in
e

PE
T 

CT

Bo
ne

 D
en

si
ty

Br
ea

th
 T

es
tin

g

Nu
cl

ea
r M

ed
ic

in
e 

Th
er

ap
y

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 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.
For safety reasons, all children under 8 years of age are not permitted to accompany you into the examination room for your ultrasound scan unless it is the child that is the patient.

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.

Patient preparation details  
will be confirmed at the time 
of making an appointment.

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

BARIUM SWALLOW /  
MEAL / FOLLOW-THROUGH 
(SMALL BOWEL SERIES)
Please do not have 
anything to eat or drink 
for 6 hours before your 
appointment. Please note, 
your 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. 
This examination may also 
require an oral preparation 
to be drunk.

CT SCAN   CORONARY 
ANGIOGRAM &amp; CALCIUM 
SCORING
Please follow your 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. Please 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 
Please 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
Please 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)
Please do not have anything 
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
You will need to have a  
full bladder. Please drink  
1 litre of water based fluid, 
finishing 1 hour before  
your appointment. Do  
not empty your bladder.

ULTRASOUND SCAN    
OBSTETRIC
You will need to have a  
full bladder. Please drink 
500ml of water based fluid, 
finishing 1 hour before your 
appointment. Do not empty 
your bladder.

PAEDIATRIC PATIENTS
Specific instructions will  
be given at time of booking. 


</pre>
</body>
</html>