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REFERRAL AND/OR REQUEST(S) FOR DIAGNOSTIC IMAGING
Call for appointment. See over for nearest location.
Time of appointment:
Date:
PATIENT DETAILS:
Name:
DOB:
Telephone:
Address:
Sex:
M
F
Medicare No:
Your Ref:
REQUEST FOR:
General X-Ray
Nuc Med
RESULTS:
Routine
US
CT
OPG
Echocardiography
Urgent
Fax
MRI
Phone
Mammography
Fluroscopy
Cone Beam CT
Take Film
BMD
Cardiac Services
Copy to
PROCEDURE & CLINICAL NOTES:
Y
MRI
N
Euflexxa injections x 3 separated by 2 weeks
+/- ORBITS +/- SKULL +/- CHEST X-RAY +/- ABDOMEN X-RAY
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
History of Metalwork, Grinding, Welding?
Cardiac Pacemaker?
Cardiac Valve Replacement
In Vivo Electronic Device
Brain Aneurysm Clip
Ear Implant
Eye Surgery or Metal in Eye
For female patients, is there any chance the patient may be pregnant?
CT Scanning
No
Nuclear Medicine Bookings
If diabetic, does treatment include
Metformin?
Yes
Y
N
What is current renal function?
151-153 Furlong Rd, St Albans
Western Private Hospital,
Cnr Marion & Eleanor Sts, Footscray
405 Burwood Hwy, Vermont
Monash House,
Suite 1, 271 Clayton Rd, Clayton
Date of renal function:
Please refer to table on back.
REFERRER DETAILS:
IMPORTANT NOTE:
Dr Lisa Wang
13A Douglas Pde, Williamstown VIC 3015
•Please bring this form, your Medicare card, DVA card, current concession card and
previous films with you.
•Please call clinic for examination preparation requirements.
Signature:
Date:
The consulting radiologist, in exercising due care and skill, may conduct a patient
consultation as deemed necessary. The radiologist will engage with the referrer to consider
any further diagnostic imaging requirements that may
result from the consultation.
CLEAR FORM
CENTRAL
Imaging @ Olympic Park
Carlton
LOCATION
Level 1, 149 Station Street
280 Coventry Street
AAMI Park, 60 Olympic Boulevard
32 Queensberry Street
ADDRESS
9489 8884
8617 0226
9420 1700
9671 3711
TEL
9489 8887
8617 0229
9420 1777
9671 3118
FAX
Monday to Saturday
Monday to Friday
Monday to Sunday
Monday to Friday
OPENING DAYS
Direct Radiology
South Melbourne
Suite 5, 285 Carlisle Street
286 Clyde Road
Suite 2, 18 Langmore Lane
600 Glen Huntly Road
9/115 Hall Road
Suite 4, 10 Jamieson Street
Suite 1, 271 Clayton Road
1383 Centre Road
130-132 South Gippsland Highway
54 - 56 Princes Highway
24 Playne Street
59 Beach Street
81 Paisley Street
151 - 153 Furlong Road
338-340 Hampshire Crescent
27 Princes Highway
89-91 Ferguson Street
Western Private Hospital
Corner Eleanor & Marion Streets
156 Millers Road
1 Treadwell Road
530-532 Melton Highway
Unit 3, Medical Centre
1/211 Barries Road
Unit 1, 500 High Street
8773 5748
8552 9552
8773 5788
8773 5778
9528 2300
8770 7977
9262 5488
8546 6288
9565 4888
5911 5200
8788 9888
8770 7930
8770 7988
9688 2888
8312 7888
8311 6888
8734 3222
9399 6000
9236 4088
8312 5444
9334 3434
8361 4488
8764 2100
8401 8401
9799 9175
9527 3788
8768 9691
9769 7988
9528 5144
9782 9017
9583 6359
9543 7122
9543 1919
5911 5209
9792 2253
9978 9487
9781 4476
9687 9485
9356 0158
8311 6889
9741 1585
9397 4811
9317 0899
8312 5455
9379 0011
9449 3066
8764 2109
9408 4457
Monday to Friday
Monday to Friday
Monday to Friday
Monday to Saturday
Monday to Saturday
Monday to Friday
Monday to Friday
Monday to Friday
Monday to Saturday
Monday to Saturday
Monday to Saturday
Monday to Friday
Monday to Saturday
Monday to Friday
Monday to Saturday
Monday to Friday
Monday to Saturday
Monday to Saturday
Monday to Friday
Monday to Saturday
Monday to Saturday
Monday to Friday
Monday to Saturday
Monday to Saturday
Monday to Friday
Monday to Saturday
Direct Radiology Fairfield
NORTH
Epping
Corner Fordholm Road &
Stuart Avenue
9756 7675
5979 2788
Footscray
St Albans
Sunshine
Werribee
Williamstown
SOUTH–EAST
Balaclava
Berwick
Berwick MRI
Elsternwick
Carrum Downs
Cheltenham
Clayton Monash House
Clayton Centre Road
Cranbourne
Dandenong
Frankston Central
Frankston
Footscray - WPH
Niddrie
Sydenham
WEST
Altona North
Melton
Hampton Park
9756 7605
Monday to Friday
Monday to Friday
Monday to Saturday
Monday to Saturday
5971 9978
9553 1191
5929 8109
8554 6709
9574 0244
Monday to Friday
Monday to Saturday
Monday to Friday
Monday to Friday
Monday to Saturday
Monday to Friday
Monday to Saturday
Monday to Saturday
Monday to Friday
Monday to Friday
Monday to Friday
66 Main Road
8552 8888
5929 8100
8554 6700
8558 5888
9729 2998
9898 0186
9813 4455
8203 2109
9822 8397
9755 5143
9850 6527
9886 1955
9802 9641
9802 9641
9841 2566
Monday to Friday
Monday to Friday
Shop 2, 37 Victoria Street
Suite 2, 999 Nepean Highway
20 Station Street
Suite 7, 67 Eramosa Road West
12 -14 Windsor Avenue
9729 2258
8843 6888
8808 7688
8203 2100
9815 9388
9724 7300
9468 6788
9814 6666
9814 6633
9814 6633
9841 2555
5783 1898
5781 1475
Hastings
157 Scoresby Road
Suite 2, 28-32 Arnold Street
607-609 Riversdale Road
538 Mountain Highway, Bayswater
1155 Malvern Road
Suite 1, 1101 Wellington Road
Level 3/200 High Street
399 - 401 Burwood Highway
411 Burwood Highway
405 Burwood Highway
Gnd Flr, 645-647 Burwood Highway
5783 8388
5734 2777
Direct Radiology
Monbulk
Moorabbin
Pakenham
Somerville
Springvale
EAST
Boronia Central
Box Hill
Camberwell
Knox
Malvern
Rowville Wellness
Templestowe Lower
Vermont
65 Wellington Street
Kilmore Hospital Rutledge Street
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DOPPLER
MAMMOGRAPHY
CT ANGIOGRAPHY
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CT
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NUCLEAR MEDICINE
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CR00023 / 0122
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ULTRASOUND
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FLUOROSCOPY
Your Practitioner has recommended you use Capital Radiology. You may choose another provider but please discuss this with your Practitioner first.
Vermont Private
REGIONAL
Wallan
Kilmore
GENERAL X-RAY