Diagnosticare Referral
Urgent Examination
Yes
No
Patient Details
First Name
Last Name
D.O.B
Phone Number
Address
Email Address
Examination Requested:
Clinical Details:
Referring Doctors Details:
Copies To
Which Lab Performed Last Blood Test:
Referral Dated
Doctors Name/Signature
Provider Number
Provider Email
Specialty
GP
Specialist
Other
CT Scanning
If diabetic, does treatment contain Metformin?:
Yes
No
What is current renal function?:
Date of renal function
MRI
(Specialist referrals are now bulk billed).
Important: Does the following relate to your patient?:
History of welding, grinding or sheet metal work
Yes
No
Cardiac pacemaker
Yes
No
Brain aneurysm clip:
Yes
No
Cochlear implant:
Yes
No
What is current renal function?:
Date of renal function
MRI Patients under sixteen (16) years of age
HEAD
Unexplained seizures
Unexplained headache where significant pathology is suspected
Paranasal sinus pathology
Elbow
Where a significant fracture or avulsion injury is suspected
HIP
Suspected septic arthritis
Suspected slipped capital femoral epiphysis
Suspected Perthes disease
SPINE
Significant trauma
Unexplained neck or back pain with associated neurological signs
Unexplained back pain where significant pathology is suspected
WRIST
Where scaphoid fracture is suspected
KNEE
For internal joint derangement
MRI Patients sixteen (16) years and older
HEAD
Unexplained seizures
Unexplained chronic headache with suspected intercranial pathology
SPINE
Suspected cervical radiculopathy
Cervical spine trauma
KNEE
Following acute knee trauma:
Inability to extend knee suggesting the possibility of acute meniscal tear
Clinical findings suggesting acute anterior cruciate ligament tear
COVID-19
Has the patient returned from O/S in the past 14 days.
Yes
No
Does the patient have any Flu like symptoms
Yes
No
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