REFERRAL FORM

This form is available only as a preliminary booking medium and does require the patient to bring a

completed and signed referral form on arrival at Wollongong Nuclear Medicine.

If you do not possess any referral forms can be downloaded in a PDF format either in

Colour or Black & White and includes Maps and a Questions & Answers procedure detail page

Colour                                     Black & White

To 

      Consultant Physicians in Nuclear Medicine

 

Patients Name

 

Address

Phone

  

 

 

 CARDIAC IMAGING                                                                                     

 

  Myocardial Perfusion Study                 Thallium Myocardial Viability Study 

  Gated Heart Pool Study                

 

 PULMONARY IMAGING                                                                                

 

  VQ Lung Study                                DTPA Lung Clearance Scan           

  Lung Reduction Study                        

 

  SKELETAL IMAGING                                                                                  

 

 Bone Study                                     Bone Marrow Study                     

  Bone Mineral Density Study            

 

  GASTROINTESTINAL IMAGING                                                                    

 

 Hepatobiliary Study                           Liver/Spleen Study                     

 Gastric Emptying Scan                       Colon Transit Study                    

 Oesophageal Transit Study                 RBC Liver Study                         

 RBC GIT Bleed Study                          Meckel's Diverticulum Study         

 SeHCAT Study                             

 

  RENAL STUDY                                                                                          

 

  DTPA Renal Study                             DMSA Renal Study                      

 

   TUMOUR IMAGING                                                                                    

 

 Gallium Study                                    I¹²³ or I¹³¹  - MIBG Study           

  In¹¹¹ - Octreotide Study                    I¹³¹ Whole Body Study                

  Thallium Whole Body Study             

 

  INFECTION IMAGING                                                                                 

 

 Labelled White Blood Cell Study            Leukoscan                                

  Gallium Study             

 

  ENDOCRINE IMAGING                                                                                

 

 Thyroid Study                                   Sestamibi Parathyroid Study        

 

  OTHER                                                                                                   

 

  Lymphoscintigraphy                           Cerebral Perfusion Study

  Paediatric Imaging                             I¹³¹ Therapy for Thyrotoxicosis

 

CLINICAL DETAILS & RELEVANT RESULTS

 

THIS SCAN IS:

  URGENT       Please Phone results:   

                          

Please Fax results to:      

 

  ROUTINE       Please Mail or Return With Patient

 

 Referring Doctor

 

 Address

 

 Date                                         Doctors Provider Number

                     

 Phone                                   Facsimile

     

 Email

 

 

               

 

If your computer does not have Acrobat Reader you will need to

Download it to access the PDF files included in  this web site

You can download the programme from ADOBE:- : - FREE DOWNLOAD

Contact us directly at the

Wollongong Office

Phone 4220 4500

Fax    4220 4555

Email info@wollongongnuclear.com.au

Contact us directly at the

Shellharbour Office

Phone 4295 4766

Fax    4295 4711

Email info@wollongongnuclear.com.au

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