MRI Ultrasound Injection / PRPCT ScanX-rayNuclear MedicinePET ScanOther

Examination

Requesting Practitioner

Clinical Details

Allergies

Patient Details

CONTRAINDICATIONS FOR MRIPacemaker / DefibrillatorNeurostimulatorCochlear Implant

POSSIBLE CONTRAINDICATIONS Aneurysm ClipStapedectomyMorphine / Insulin PumpAAA Stent

POTENTIAL MRI HAZARDSPrevious metallic foreign body in eye (e.g. from welding / grinding) Please perform Orbit X-ray (Tick if Required)

ShrapnelHistory of severe renal disease or dialysis for patients requiring contrast (Please provide recent creatinine levels or arrange for blood test)

Dr Brendan AdlerDr Eamon Koh Dr Michael Krieser Dr Michael Mason Dr Patrick Ng

Bookings telephone: 08 6382 3888Fax: 08 6382 3800Email: bookings@envisionmi.com.au

SPECIALISED SPORTS IMAGING

Next appointment datePatient to waitPlease phone Dr.

URGENCY OF REPORT

Surname

First Name

DOB

Telephone (H) (M)

Please bring any previous scans or x-rays with you.

SPORTS IMAGING

Body Part

Signature

Date

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WEMBLEY 178-190 Cambridge Street (opp. St John of God, Subiaco)

Tel: (08) 6382 3888 Fax: (08) 6382 3800 Email: bookings@envisionmi.com.auEnvision is a private billing practice and payment is required on the day of your test.

Your doctor has recommended you use Envision Medical Imaging. You may choose another provider but please discuss this with your doctor first.

Bookings: Tel: 08 6382 3888 Fax: 08 6382 3800 Email: bookings@envisionmi.com.au

Hours of Operation: Monday to Friday 8.30am - 5.00pm Saturday 8.00am - 1.00pm

178-190 Cambridge Street | Wembley6382 3888 | envisionmi.com.au

(MRI is also available 5pm-9pm Mon-Thurs and on weekends by appointment)

MRI Patient Information

You have been referred to Envision to have an MRI (Magnetic Resonance Imaging) scan. We take pride knowing that your imaging will be done on one of our modern wide-bore, high quality 1.5T or 3T scanners. In combination with our friendly staff, the whole experience will be far more comfortable for you, virtually eliminating claustrophobia. Most importantly, the excellent image quality allows for accurate diagnosis by our specialist MRI Radiologists.

Our aim is to make this experience as pleasant as possible for you. We encourage you to bring along a phone or i-Pod of your favourite music for you to listen to during your scan (alternatively we can provide a selection of music for you.)

The MRI scanner will make various tapping or buzzing noises as part of the normal process of acquiring your images. A scan of a single region generally takes between 15 - 25 minutes, though some more complex studies can take a little longer.

MRI does not use ionizing radiation like X-rays or CT scanning. The MRI scanner is however, a very powerful magnet so some patients with certain implants or metallic/electronic devices cannot have an MRI scan.

Most metal screws, clips & rods used in surgery are safe to be scanned as they are made of titanium (non-magnetic), but we will ask you about these on the day of your scan. You may be required to remove jewellery prior to your scan.

Please phone to arrange an appointment or email us and we will contact you with a convenient time and day. Please fax the front of this form prior to your appointment. Envision Medical Imaging is a private billing practice with payment required on the day of your examination.

Free Parking is available at the rear of the building.

Please note: Due to a traffic island you cannot turn right into Connolly Street if heading West on Cambridge Street.

If using Public transport there is a bus-stop immediately in front of our building (Route No. 81, 84, 85, 91, 92, 95) Subiaco train station is less than a 5 minute stroll.

PLEASE CONTACT OUR HELPFUL MRI STAFF PRIOR TO BOOKING AN APPOINTMENT WITH ANY QUESTIONS, OR IF YOU HAVE ANY OF THE FOLLOWING IMPLANTED DEVICES

(08 ) 6382 3824

P

Subi TrainStation

SJOGHospital

Marmion St

Davy S

t

Connolly S

t

Station S

t

Elverd Lane

Cambridge St

Main

StKarrin

yup Rd

North Beach Dr

Mitch

ell Fw

y

Albert St

Cedric

St

Riseley S

tJoseph S

t

McC

ourt St

Coomoora Rd

Salvado Rd

Andrea Ln

Garden CityShopping Centre

P

Subi TrainStation

SJOGHospital

190 178P

Pacemaker/DefibrillatorCochlear ImplantAneurysm ClipProgrammable VP Shunt

NeurostimulatorStapedectomy (Inner Ear)Morphine/Insulin PumpMultiple Coronary Stents

Any surgical implant that has been in situ less than 6 weeks

MRI Fee Information

Due to restrictions imposed on MRI access throughout Australia, most of our MRI scans do not attract a Medicare rebate; with the exception of specific adult (over 16 years old) – head, spine, knee scans and paediatric (under 16 years old) – head, spine, knee, hip, elbow, wrist scans referred by General Practitioners. At Envision, your Specialist, GP, Physiotherapist, Podiatrist or other health professional can refer you directly for an MRI at an affordable price. Most other radiology practices require you to have a specialist’s referral.

There are further advantages for you:1. You will be able to get a scan quickly and therefore be able to receive any

required treatment from your Doctor sooner.2. MRI is often superior to other imaging modalities meaning you can

potentially avoid having other unnecessary radiation scans or tests.

Having your MRI scan at Envision will likely save you time whilst giving you an accurate diagnosis on the most comfortable, high quality MRI Scanners in Perth.

Please note that payment will be required on the day of your examination.

CT MRI X-RAY ULTRASOUND PET NUC MED DENTAL