medical imaging request townsville hospital & health service
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MEDICAL IMAGING REQUESTTownsville Hospital & Health Service
X-ray - CT - Ultrasound - Nuclear Medicine - MRI - Fluoroscopy - Angiography
The Townsville Hospital - IMB 47100 Angus Smith Drive, Douglas, Qld. 4814Ph: 07 4433 1500Fax: 07 4433 1501 (external use only)
URGENT REQUESTS - Please contact Radiology
Material Number: 10150475 Form Revision: March 2013
DNA Rebook On Hold Cancelled Int: Appt Details:
Clinical History & Provisional Diagnosis:(Include relevant surgery, imaging and pathology results.)
Pregnant? Yes / NoInfectious? Yes / NoAllergies? Yes / No - Specify:
MANDATORY INFORMATION FOR ACCEPTANCE OF THIS REQUEST
UR:
Surname:
Given Name:
DOB: / /
Phone:
Home Address:
RequestedExamination:
Female Ward:Bed No:Clinic:
Consultant / Specialist MOFull Name (Print)
Consent Obtained? Interventional Procedure Renal Impairment General Anaesthetic
Requested by: (Print Full Name)
Declaration: I consider the benefits of the examination justify the risk to the patient.
Signature:
Contact: Ph: Pager:
Billable PatientDr Provider Number:
Date: / /
Date for next clinical review: / /Forward Additional Report to:
Name:
Address:
Male
Room: Acc No:
Scan to QRIS / PACSNo Images:
Radiologist Protocol - Initials
Today Next 2 days Next 5 days
I.V. Contrast Oral Rectal
MEDICAL IMAGING USE ONLY
Radiographer: Transport: W/chair Bed Nurse Escort Extras:
YES
Radiographer’s Initials:
Team Leader Signature:
MEDICAL IMAGING FINAL CHECK
Patient identification verifiedProcedure & consent verifiedCorrect side & site verifiedCorrect Patient data & side markers
Risk Factors for CT, MRI, IVP, Angiography Nil OR >70 years
Hx renal impairment Diabetic On Metformin / nephrotoxics If yes to any of the above please complete Blood Requests
Creatinine eGFR
Test Results - no older than 1 mth / /
For InterventionCoag profile required (include INR)
Completed No Yes Auslab / QML / S&N / Other
Test Results - no older than 1 wk / /
Anticoagulants / specify:
Previous reaction to contrast?Asthmatic
MANDATORY INFORMATION FOR CT, MRI & INTERVENTIONAL PROCEDURES
DOWNTIM
E