STANDARD REFERRAL - Perth Radiological Clinic
2
Renal Abdominal Liver Liver US & Elastography Pelvic Obstetric Other JAN 2021 Do not send reports to my health record PLEASE TELL US IF YOU HAVE HAD PREVIOUS IMAGING SO DIGITAL IMAGES CAN BE RETRIEVED perthradclinic.com.au STANDARD REFERRAL TO BE COMPLETED BY REFERRING PRACTITIONER DOCTOR’S PROVIDER DATE OF SIGNATURE .............................................................. NUMBER........................................... REQUEST ........................................... CLINICAL DETAILS (Please send previous films) .............................................................................................................................................................................................................................. .............................................................................................................................................................................................................................. .............................................................................................................................................................................................................................. .............................................................................................................................................................................................................................. .............................................................................................................................................................................................................................. .............................................................................................................................................................................................................................. .............................................................................................................................................................................................................................. PATIENT'S NAME................................................................................................................. PRIVATE ADDRESS .......................................................................................................................... WORKERS’ COMP ......................................................................................................................................... MVA DATE OF BIRTH ...................................................... FEMALE PATIENTS 12-50 YRS DATE OF L.M.P . ............................... RADIOLOGIST CONSULTATION REFERRAL Plain Film Ultrasound Doppler CT MRI Bilateral Mammogram Single Breast or Bilateral Breast lump/s Mass Plain (Localised) Tenderness (Localised) Follow up of previous malignancy Family History Breast Ultrasound (Bilateral) Breast Ultrasound (one side) FNA Bone Densitometry (DEXA) SHOULDER ULTRASOUND Evaluation of injury to Tendon, Muscle or Muscle/Tendon Junction Rotator Cuff Tear/Calcifcation/Tendinosis Biceps Subluxation Capsulitis and Bursitis Evaluation of Mass including Ganglion Occult Fracture Acromioclavicular Joint Pathology KNEE ULTRASOUND Abnormality of Tendons or Bursae about the Knee Meniscal Cyst, Popliteal Fossa Cyst, Mass or Pseudomass Nerve Entrapment, Nerve or Nerve Sheath Tumor Injury of Collateral Ligaments MULTISLICE CT ARTHROGRAM Knee Meniscal & Cruciate Ligament tears Knee Assessment of Chondral Surfaces Other NUCLEAR MEDICINE Bone Scan - Whole Body Bone Scan - Localised V/Q Lung Scan Exercise Cardiac Stress Dipyridamole Cardiac Stress Isotope Cystogram Hepatobiliary Renal - DTPA Renal - DMSA Renal with Diuretic Thyroid Patient Weight .........................................
Transcript of STANDARD REFERRAL - Perth Radiological Clinic
RenalAbdominal LiverLiver US & Elastography PelvicObstetricOther
JAN
202
1
Do not send reports to my health record
PLEASE TELL US IF YOU HAVE HAD PREVIOUS IMAGING SO DIGITAL IMAGES CAN BE RETRIEVEDperthradclinic.com.au
STAN
DA
RD
REFER
RA
L
TO BE COMPLETED BY REFERRING PRACTITIONER
DOCTOR’S PROVIDER DATE OFSIGNATURE .............................................................. NUMBER........................................... REQUEST ...........................................
CLINICAL DETAILS (Please send previous films)..............................................................................................................................................................................................................................
..............................................................................................................................................................................................................................
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PATIENT'S NAME................................................................................................................. PRIVATE
ADDRESS .......................................................................................................................... WORKERS’ COMP
......................................................................................................................................... MVA
DATE OF BIRTH ......................................................FEMALE PATIENTS 12-50 YRS DATE OF L.M.P. ...............................
RADIOLOGIST CONSULTATION REFERRAL
Plain Film Ultrasound Doppler CT MRI
Bilateral Mammogram Single Breast or Bilateral Breast lump/s Mass Plain (Localised) Tenderness (Localised) Follow up of previous malignancy Family HistoryBreast Ultrasound (Bilateral)Breast Ultrasound (one side)FNABone Densitometry (DEXA)
SHOULDER ULTRASOUND
Evaluation of injury to Tendon, Muscle or Muscle/Tendon Junction Rotator Cuff Tear/Calcifcation/Tendinosis Biceps Subluxation Capsulitis and Bursitis Evaluation of Mass including Ganglion Occult Fracture Acromioclavicular Joint Pathology
KNEE ULTRASOUND Abnormality of Tendons or Bursae about the Knee Meniscal Cyst, Popliteal Fossa Cyst, Mass or Pseudomass Nerve Entrapment, Nerve or Nerve Sheath Tumor Injury of Collateral Ligaments
MULTISLICE CT ARTHROGRAM Knee Meniscal & Cruciate Ligament tears Knee Assessment of Chondral Surfaces Other
NUCLEAR MEDICINEBone Scan - Whole Body Bone Scan - Localised V/Q Lung Scan
Exercise Cardiac Stress Dipyridamole Cardiac Stress Isotope Cystogram Hepatobiliary
Renal - DTPA Renal - DMSA Renal with Diuretic Thyroid
Patient Weight
.........................................
Location Guide Appointment requests can be made at perthradclinic.com.au
ECKO ROAD
3056 Albany HighwayPh: 9391 0100Fax: 9391 2019Mon - Fri: 8.30 - 5.00Service available to emergencydepartment patients after hours.
ARMADALE HOSPITAL BENTLEY HOSPITAL
Bentley Health Service (B Block) Mills Street Ph: 9232 3800 Fax: 9350 5644 Mon - Fri: 8.30 - 5.00
BETHESDA HOSPITAL
25 Queenslea Drive Claremont Ph: 9286 0400 Fax: 9286 0430 Mon - Fri: 8.30 - 5.00
BOORAGOON
260 Leach Highway Cnr Norma Road Ph: 9333 5600
Fax: 9317 8368 Mon - Fri: 8.30 - 5.00 Sat: 8.30 - 12.00
GOSNELLS
122-126 Stalker Road Ph: 9394 9900 Fax: 9394 9960Mon - Fri: 8.30 - 5.00
CORFIELD STREET
STALKER ROAD
Hollywood Consulting CentreEntrance 5, Ground FloorSuite 2, 91 Monash Ave,NedlandsPh: 6373 0000Fax: 6373 0020
HOLLYWOOD
Mon - Fri: 8.30 - 5.00
HOLLYWOODMEDICAL CENTRE
WIN
THRO
P AV
ENU
E
Gate 5
EY
HOLLYWOOD PET CENTRE
Entrance 5, Ground Floor, Suite 14 Hollywood Medical Centre85 Monash Avenue, Nedlands Ph: 9386 7800Fax: 9386 7888Mon - Fri: 8.30 - 5.00
HOLLYWOODMEDICAL CENTRE
WIN
THRO
P AV
ENU
E
Gate 5
INNALOO
8 Odin Road Ph: 9329 5400 Fax: 9329 5490Mon - Fri: 8.30 - 5.00
JOONDALUP HEALTH CAMPUS
Shenton Avenue Ph: 9400 0500 Fax: 9400 9033 Mon - MRI 7.00am - 10.00pm
Fri: 8.00 - 5.30
(7 days a week)
JOONDALUP
Shenton HouseLevel 157 Shenton Ave (cnr Grand Blvd) Ph: 9400 0600
Fax: 9400 0690Mon - Fri: 8.30 - 5.00
KALAMUNDA
Elizabeth Street Ph: 6293 1799 Fax: 6293 1781 Mon - Fri: 9.00 - 5.00
ECKO
ROAD
SJG MIDLAND HOSPITAL
Midland Public & Private Hospitals1 Clayton StreetPh: 6274 3500
Fax: 6274 3590 Mon - Fri: 8.30 - 5.00
RAILWAY PDE
LLOY
D ST
CLAYTON ST
YELVERTON DVE
CENTENNIAL PL
GREAT EASTERN HWY
ST JOHN of GOD PRIVATE & PUBLIC
HOSPITALS
MIDLAND
21-23 Victoria Street Ph: 9374 2600
Fax: 9374 2691Mon - Fri: 8.30 - 5.00 Sat: 8.30 - 12.00
MORLEY
29 Collier Road Ph: 9375 0700
Fax: 9375 0790 Mon - Fri: 8.30 - 5.00
WALTER ROAD WEST
CO
LLIE
R R
OAD
CH
AR
NW
OO
D S
TGALLERIASHOPPING
CENTRE
MOUNT MEDICAL CENTRE
Level 2, 140 Mounts Bay RoadPh: 6228 6200
Fax: 6228 6240 Mon - Fri: 8.00 - 5.00
Sat: 8.00 - 12.00MRI 7.00 am - 10.00 pm
(7 days a week)
FIONA STANLEYMAIN HOSPITAL
MURDOCH
Wexford Medical CentreGround Floor,3 Barry Marshall Parade, Murdoch Ph: 9312 7800
Fax: 9312 7878 Mon - Fri: 8.30 - 5.00
NOLLAMARA
217 Wanneroo Road
Ph: 9440 7400 Fax: 9440 7490
Mon - Fri: 8.30 - 5.00 Sat: 8.30 - 12.00
Balcatta
HAMMAD STREET
CANNING HIGHWAY
FRED JONES RESERVE
PALMYRA
Cnr Canning Highway and Antony StPh: 9333 7800
Fax: 9333 7888 Mon - Fri: 8.30 - 5.00
ROCKINGHAM
215 Willmott DriveWaikiki Ph: 9599 3900 Fax: 9592 9893 Mon - Fri: 8.30 - 5.00
ROCKINGHAMPRIVATE
HOSPITAL
SOUTH PERTH
South Perth Hospital 1 Burch Street Ph: 9474 7600 Fax: 9474 7630Mon - Fri: 8.30 - 5.00
SUBIACO
Magnetic Resonance Centre 127 Hamersley Road Ph: 9380 0900 Fax: 9380 4188 Mon - Fri: 8.30 - 5.00MRI 7.00am - 10.00pm
(7 days a week)
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