Myocardial Perfusion Imaging Request	
Patient Details

Name:  <PtFullName>

Address:  <PtAddress>

Date of Birth: <PtDoB>    
Telephone (H): <PtPhoneH>
Telephone (B): <PtPhoneWk> 
Med. No.: <PtMCNo>	
CLINICAL DETAILS:		PATIENT CATEGORY:		RESULTS:	
Tick which of the following apply:
O	Chest Pain: Typical or atypical angina
(extertional and/or GTN relieved)
O	ECG changes consistent with CAD
O	Known CAD with symptoms not controlled or evolving
O	? Visible myocardium
O	Post congenital heart disease surgery
O	Quantification of ischaemia pre-intervention
O	Indeterminate lesion on CTCA or angiography
O	Unexplained dyspnoea
O	Pre-op cardiac risk assessment (one of CAD, heart failure, CVA, TIA, renal impairment, IDDM)
	O	PTE
O	W/C
O	Pension	O	Vet/Aff
O	TAC	O	Telephone report
(No.                                  )

O	Films & report return with patient

O	Facsimile report
(No.                                  )	
	
Sex: Male O   Female O  Is the patient pregnant? Yes O No O			

ADDITIONAL CLINICAL DETAILS:		
REFERRING DOCTOR DETAILS:	

O	Date of last myocardial perfusion study	Referring Doctor: <DrName> 
Provider Number: <DrProviderNo>
<Practice>, 
<UsrAddress>
Phone: <UsrPhone>   Fax: <UsrFax>

Referral Date: <TodaysDate>
Patient has consented to being contacted by I-MED Radiology to arrange appointment(s).	
REFERRAL/REQUEST(S) FOR:		COPIES TO:	
For Medicare rebate, patients must meet one of the following criteria:
Tick which of the following apply.

O	Stress echo unlikely to be adequate due to a) body habitus, including obesity, b) arrhythmia, including atrial fibrillation
O	Unable to exercise adequately for maximal exercise test
O	Failed previous stress echo (in last 24 months)		
	DOCTOR’S SIGNATURE:	
Why choose I-MED Radiology?

•	Bulk billing available for most Medicare eligible procedures for pension and healthcare card holders
•	Same day appointments available*
•	Fast report turnaround
•	High quality, exceptional patient care
•	Over 300 Specialist Radiologists
•	World class technology
As a patient, you trust your doctor to make decisions regarding your health. So you know that your referral to I-MED Radiology puts you in good hands.
*subject to patient preparation requirements and availablity	
DATE: