THEPRINCE OF WALES

HOSPITALAND

MEDICAL IMAGING DEPARTMENT RAH1>WICK

Medical Imaging Department - Magnetic Resonance Imaging (MRI)Level 0, Barker Street, Randwick NSW 2031

Telephone: (02) 93822310 Fax: (02) 9382 2340 Inpatient Fax: 22316

A Booking for MRI scan has been made for you at Prince of Wales Hospital20th November2009 06:20 pm

arne: Marko KrsmanovicMRN: 8503419

Address: 19 Vallingby Avenue,DOB: 20/04/1989

Hebersham, 2770

You Must Telephone the MRI department to Confirm Your Appointment As Soon As Possible------ ~ - - - -

There are important safety considerations in relation to MRI scan . Please complete the following;Height: Weight: Occupation: _

Circle YES or NO to each question below and Call MRI department if answe red -YlrS to any QuestionsDo you have any of the following;

- Cardiac Pacemakerl Defibrillator?- Have you ever done welding or metal work?- Metal injury to eyesl eye surgery?- Cou ld you be pregnant?- Do you have claustrophob ia?- Brain aneurysm clips or coils- Neuro stim ulators / Patches?- Implanted Devices (Le. Insulin pump etc)?- Cochlear or Stapes Implant?- Artificial heart Valve or Intravascular Stent?- Recent insertion of Artific ial j oint (with last 4 weeks)?- Metal rods/plates/sc rews/nails/implants?- Shrapnel injur ies?

YESYESYESYESYESYESYESYESYESYESYESYESYES

NONONONONONONONONONONONONO

Do you have any kidney problems? YES NO

Do you have any known allergies? YES NO

if YES details : _

if YES details; _

- Have you ever had any surgery?

Previo us MRI Scans

- YES NO -if YES deta i l s:~ -_=-~- _

Have you had an MRI scan before? YES NO

DATE: TYPE: LOCATION: _

In order to ensure compliance with the Commonwealth Department of Health regu lations and Medicarerebate eligibility please complete the following

MEDICARE CARD NO EXPIRY DATE ..

I confi rm the above details are true,

Signed Date .Should any of the above change please call the MRI department immediatelv. withi n office hours 9-50m.

- Artificial heart Valve or Intravascular Stent? YES NO- Recent insertion of Artificia l j oint (with last 4 weeks)? YES NO- Metal rods/plates/sc rews/nails/implants? YES NO- Shrapnel injuries? YES NO

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The Prince of Wales Hospital & Community Hea lth Services

MEDICAL IMAGING DEPARTMENT - MAGNETIC RESONANCE IMAGING (MRI)Lev el 0 Barker St reet Randwick NSW 2031

Telephone: (02) 93822310. Facsimile: (02) 9382 2340

ABOUT YOUR MRIKeep this sheet for you r information.

Name: Marko Krsmanovic

Time: 06:20 pmAppointment Date: 20th November 2009

"m ARRIVE "30 MINUTES BEFOREn !il '11 . • '1, ,Ii rt

MRI (Mag netic Resonance Imaging) is the latest method of medi cal imaging. It uses a strong mag netic fieldan d radio-frequency pulses. Due to the strong magnetic field som e pat ients are unsuitable for the examination,for example those with pacemakers , neurostimul ators, cochlear implants, ane urysm clips and some heartvalves. Metal in the eye is also dangerous. It is important that you answer the questions in the magneticsurve illance questionnaire carefu lly.

-~ -- - -Before you r scan you will be asked to remove your jewe llery, watches, keys, hair pins, hearing aids andwalle t, which can be locked in a safe place during the scan. The magnetic field could wipe credit cards andruin the timing mechanism in watches . You will need to change into a hospital gown. Dentures may need tobe removed.

Once in the scan room you will be placed on a motorised table, usually lying on your back. It is importantthat you are as comfor table as possible at the beginning of the examinat ion as it is essent ial that you remainstill during the scan.

A coil wi ll be placed around the area to be examined . This acts as an antenna to the radiofrequency pulse .The lable will be moved slowly into the sca nner which looks like a tunnel. You will not feel anything duringthe sca n but will hea r an intermittent humming or thumping noise. These sounds are normal and no causefor alarm.

It is possible for you to communicate with the radiographer during the examination and the radiographer willbe talking to you durin g the exam ination letting you know how long each scan will take. Each examinationusually consists of a number of sca ns to get the inform ation required. The whole examination usually takes30 minutes to 1 hour. Some examinations require a cont rast agent, which is injected through a small needleplaced in a ve in in your arm .

The images produced by the MRI mach ine wi ll be reviewed by a radio logist. A report will be sent to yo ur owndoctor w ithin a few days of the examinat ion.

If you still have any qu estions about the examinat ion please do not hes itate to ask our staff.PLEASE-ND-TE: -- .. --

- Arrive 30 minutes before the appointment time for magnetic surveillance checking .

- The MRI Unit is situated on Level 0 of the Prince of Wales Hosp ital at the Ba rker St reet side of the hospital.Parking is available in the Randwick shopp ing centre car parks and the hospital car park (Barker St entrance).

- Dur ing the examination you will need to remove glasses, hearing aids, credit cards, watches, jewellery ,dentures . Valuables which cannot be left at home will be locked in safe storage during your scan .

- Do not wear ha irspray or make-up on the day of the appointment as it may alter the quality of the pictures.

- You may bring in a CD to listen to during your sca n.

- Telephone to confirm your appointment - complete and sign the questionnaire and return it by mail or fax .

- BRING ANY RELEVANT X-RAYS AND SCANS WITH YOU

- REME MBER TO BRING YOUR MEDICA RE CARD WITH YOU TO THE APPOINTMENTI( IS POSSIOle TOr you to communicate wnn me radiographer ounnq me examination and me radiographer willbe talking to you durin g the exam ination letting you know how long each scan wi ll take. Each examinationusually consists of a number of scans to get the inform ation required. The who le examination usually takes30 minutes to 1 hour. Some exam inations require a cont rast agent, which is injected through a small needleplaced in a vei n in your arm .