<html>
<head>
<meta charset="UTF-8"/>
<meta name="tikaGenerated" content="true"/>
<meta name="date" content="2019-06-12T02:05:54Z"/>
<meta name="xmp:CreatorTool" content="Adobe InDesign CC 14.0 (Macintosh)"/>
<meta name="trapped" content="False"/>
<meta name="meta:creation-date" content="2019-05-28T01:29:01Z"/>
<meta name="created" content="Tue May 28 10:59:01 ACST 2019"/>
<meta name="xmpTPg:NPages" content="2"/>
<meta name="Creation-Date" content="2019-05-28T01:29:01Z"/>
<meta name="dcterms:created" content="2019-05-28T01:29:01Z"/>
<meta name="Last-Modified" content="2019-06-12T02:05:54Z"/>
<meta name="dcterms:modified" content="2019-06-12T02:05:54Z"/>
<meta name="Last-Save-Date" content="2019-06-12T02:05:54Z"/>
<meta name="meta:save-date" content="2019-06-12T02:05:54Z"/>
<meta name="producer" content="Adobe PDF Library 15.0"/>
<meta name="modified" content="2019-06-12T02:05:54Z"/>
<meta name="Content-Type" content="application/pdf"/>
</head>
<body>
<pre>
PA
TI

EN
T 

D
ET

AI
LS

Name: Appointment Time: Day:

Date: Location:

Address:   Interpreter      
Language:

DOB:

Gender:   
  Male       Female      Unspecified

Patient type:    
  Medicare eligible     MVA   
  Work injury       DVA   
  Non-Medicare      

Telephone No:

Medicare No:UR No:  
(if relevant) 

Outpatient Clinic: 
(if relevant)

EXAMINATION REQUEST
CL

IN
IC

AL
 D

ET
AI

LS

  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:

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.

INPATIENT / ED - PATIENT INFORMATION

  Inpatient

  ED

LOCATION TRANSPORT PATIENT NEEDS

  Ward:

  Bed/cubicle:

  Walking

  Wheelchair

  Barouche

  Bed

  Portable (X-ray/US)

  Lifter

  Oxygen

I.V. Drip

Monitored

Nurse escort

OTHER PRECAUTIONS

  Increased falls risk

  Cognitive impairment

  Special Instructions:

TEAM / UNIT

Consultant: 

Unit:

Episode sticker:

sahealth.sa.gov.au/sami 

IMAGING REQUEST



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 24hrs 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.

ULTRASOUND   
PAEDIATRICS 

Specific instructions will  
be given at time of booking. 

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 3 (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.

sahealth.sa.gov.au/sami


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