Online Referral Form - Radiography For your convenience, referrals can be submitted using the online form below, or by downloading a referral PDF (X-Ray & CT, Cardiac CT Referral Form, National Lung Cancer Screening Program) and returning it to the SmartCare team via fax (0734705852) or email. "*" indicates required fields Date of Referral* DD slash MM slash YYYY Patient DetailsName* Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Date of Birthday* Day Month Year Phone*Medicare Number*WorkCover Claim Number*Clinical Indications for Test / Relevant Medical HistoryCurrent Medication/sReferring Doctor DetailsName* DrDr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last PhoneClinic NameDoctor Provider NumberSignature*Examination Requested X-Ray CT Scan Cardiac CT National Lung Cancer Screening Program Medical History Prior myocardial infarct Prior coronary stent/angioplasty Coronary bypass graft Heart failure Currently on beta-blockers/anti-arrhythmics Currently taking ACE inhibitor Pacemaker Diabetes Renal impairment Myeloma Medical History - Specialist Referral (Medicare Eligible)One of the following criteria must be present: Patient has stable symptoms consistent with coronary ischaemia, is at low to intermediate risk of coronary artery disease and would have been considered for invasive coronary angiography. Patient requires exclusion of coronary artery anomaly or fistula. Evaluation of coronary arteries prior to non-coronary cardiac surgery. X-Ray* Skull / Facial Bones Cervical Spine Thoracic Spine Lumbar Spine Chest Abdomen Pelvis / Hips Shoulder Elbow Wrist / Hand Knee Ankle / Foot Other Other:*Which Side Left Right CT Scan* Brain Skull / Facial Bones Cervical Spine Chest (HRCT / Lung / PR Protocol) Abdomen / Pelvis Spine (specify level) Extremities (specify) CT Angiogram (specify region) Other Spine (specify level)*Extremities (specify)*CT Angiogram (specify region):*Other (please specify)*Contrast Requirements* With Contrast (eGFR) Without Contrast At discretion of radiographer With Contrast (eGFR)*CTCA* CT Coronary Angiogram CT Coronary Calcium Score Chest pain or discomfort Coronary Artery Disease Abnormal or inconclusive stress test Pre-operative assessment (cardiac risk evaluation) Follow-up after stent or bypass surgery Strong family history of early heart disease CTLA Other Studies Other Studies*Recent renal functionRecent renal function within last three(3) months required for booking a CTCA (not required for CAC only). Please include: Creatinine & Date, eFGR / CrCl & DateThis patient meets the eligibility criteria of the National Lung Cancer Screening Program* Yes No Type of screening test:* 2 yearly scan New participant Participant returning for two-year scan (57410) Interval scan to monitor previous findings (57413) Month interval scan as determined in previous NLCSP LDCT report* 1 month 2 months 3 months 6 months 9 months 12 months Any previous chest CTInclude date and radiology provider/location (if known)Family history of lung cancer in a first-degree relatives (only required for first/baseline LDCT)*(First-degree relatives include parents, siblings or children) Yes No History of any cancer* Yes No Please provide details*Referring Practitioner has registered the patient via the NCSR* Yes No Why wait or pay too much for diagnostic tests?Bulk billed appointments available within 1 week For all your heart, lung, radiography and sleep tests Book Now Referral Form Contact Us
