NCRG | E-Referral MRI

Patient Details

Patient Name *

Date Of Birth *

DD/MM/YYYY

Phone Number *

Gender *

Female

Male

Other

Age

(Auto calculated from DOB)

Patient Email Address

Booking Appointment

Radiology practice will call patient to arrange appointment

Patient will initiate appointment

Examination

MRI Knee

Knee - item 63560 - 16 to 49yrs - inability to extend the knee suggesting the possibility of acute meniscal tear

Knee - item 63560 - 16 to 49yrs - clinical findings suggesting acute anterior cruciate ligament tear

Knee - item 63513 - Under 16yrs - Scan of knee for a patient under 16 years for internal joint derangement

Knee - Patient is over 50 and understands this will not be refundable by Medicare

MRI Head

Head - item 63551 - 16yrs & over - unexplained seizure(s)

Head - item 63551 - 16yrs & over - unexplained chronic headache with suspected intracranial pathology

Head - item 63507 - Under 16yrs - unexplained seizure(s)

Head - item 63507 - Under 16yrs - unexplained chronic headache with suspected intracranial pathology

Head - item 63507 - Under 16yrs - paranasal sinus pathology which has not responded to conservative therapy

MRI Spine

Cervical Spine - item 63554 - 16yrs & over - suspected cervical radiculopathy

Cervical Spine - item 63557 - 16yrs & over - suspected cervical spine trauma

Spine - item 63510 - under 16yrs - unexplained neck or back pain including for significant trauma, unexplained neck or back pain where significant pathology is suspected or there are associated neurological signs

MRI Under 16 - Hip, Elbow, Wrist

Hip - item 63516 - under 16yrs - suspected septic arthritis, slipped capital femoral epiphysis or Perthes disease (following radiographic examination)

Elbow - item 63519 - under 16yrs - a significant fracture or avulsion injury is suspected that will change management (following radiographic examination)

Wrist - item 63522 - under 16yrs - scaphoid fracture is suspected (following radiographic examination)

MRI side

N/A

Left

Right

Both

Other examination (not listed above)

Clinical History

Clinical *

Pregnant

Yes

No

Is or may the patient be pregnant?

Contrast Allergy

Yes

No

Diabetes Metformin

Yes

No

Renal Disease

Yes

No

Creatinine level: eGFR:

Date of test

MRI Checklist

Pacemaker / Heart Valves

Yes

No

Aneurysm Clips

Yes

No

Cochlear / Ear Implants

Yes

No

Metallic foreign body to eye

Yes

No

Other metallic/electronic devices

Yes

No

Details if Yes to any of the above

Referring Practitioner

Referrer Name *

Practice Email *

PACS User or RIS ID *

(Used to login to InteleViewer or Inteleconnect)

Provider Number *

Practice Address

Copies to another referrer?

Yes

No

Copy to:

*

I am entitled under the Health Insurance Act 1973 (Cth) to make this request

Please select most appropriate branch but the appointment may be at another branch.

E-Referral MRI

Patient Details

Examination

Clinical History

MRI Checklist

Referring Practitioner

North Coast Radiology

Clarence Valley Imaging