Brighton Radiology Melbourne | Patient and Practioner Forms

Brighton Radiology has separate questions for patients and health care practitioners who are referring a patient to Brighton Radiology. At the beginning of the below form, please indicate whether you are a patient or a practitioner, so that the appropriate questions can be shown.

NOTE: We only require patients to complete the patient questionnaire if they are having an MRI. If you're unsure what imaging you require, please leave the form and we'll complete it, if necessary, when you come in for your appointment.

Fields marked with an asterisk (*) are required
Are you a patient or a practitioner?
- Patient
- Practitioner
Patient Details
Name*
First Last
Email*
Phone Number Mobile or Land line*
Address*
Address City / Suburb State Post Code
Birth Date*
DD slash MM slash YYYY
Height in cms*
Weight in kgs*
Occupation
Your usual medical doctor (GP)*
Emergency contact
Emergency contact phone number
How did you find out about Brighton Radiology?
Have you had imaging done before regarding this problem?*
- Yes
- No
Please provide details of the imaging you've had done in the past
Your Health Problem
Where is your problem area or problem areas*
Please describe where you are experiencing pain or discomfort (e.g. left ankle, lower back, right forearm, etc.)
Describe your main problem or symptoms*
Please let us know the reason why you need imaging
When and how did your problem occur*
Please include date started or approximate duration
Was there any of the following prior to or during the onset*
- Illness / infection
- Trauma
- Other significant event
Is your problem*
- Getting worse
- Not changing
- Improving
Is the pain*
- Constantly there
- Intermittent - on and off
Do you get pain travelling into your arms or legs*
- Yes
- No
Please describe the pain that is travelling into your arms or legs
Does your current problem involve any of the following:
- Tingling
- Numbness
- Weakness
Tick any / all that apply to you
Please add more details here about the tingling, numbness and / or weakness
Are you currently taking any medication, substances, vitamins, supplements or herbs*
- Yes
- No
Please add details of the medication, etc you are taking
Practitioner Referral Details
Alternatively, if you’d prefer not to complete the electronic form, you can download the form here, complete it and then either fax the form to us on (03) 9593 1876, or scan and email the form to info@brightonradiology.com.au.
Patient Details
Patient Name*
First Last
Patient Mobile or Land Line Number*
Patient Address*
Address City / Suburb State Post Code
Patient Birth Date*
DD slash MM slash YYYY
Sex*
- Male
- Female
- Mixed
Patient height in cms
Patient weight in kgs
Patient Medicare Number
Imaging Request Details
Modality required*
- General x-ray
- Long view x-ray
- CT
- Tomosynthesis (Hybrid x-ray/CT)
- MRI
Region(s) required*
(For Lumbar Spine, Lower Thoracic Spine, Cervical Spine & Knee MRI, please specify if an Upright MRI scan is also required)
Clinical details / queries*
Referring Practitioner Details
Referring Practitioner's Name*
First Last
Specialty / Profession*
Provider Number*
Practice Address*
Address City / Suburb State Post Code
Phone Number*
Fax Number*
Email*
Receive report method?*
- Email
- Fax
- Healthlink
Receive images method*
- CD
- Online viewer
- Film
If Film required for Long View X-Ray, images will be cropped. Additional charges may apply for film.
Send additional report copy to:
Name
First Last
Fax / Email
Safety Check
Is there any chance the patient may be pregnant (female only)
- Yes
- No
(If 'yes' - only MRI can be performed)
Does the patient have a cardiac pacemaker/defibrillator
- Yes
- No
(If 'yes' - MRI scans cannot be performed)
Does the patient have a cochlear implant or neurostimulator
- Yes
- No
(If 'yes' - MRI scans cannot be performed)
Does the patient have a ventriculoperitoneal shunt
- Yes
- No
(If 'yes' - MRI scans cannot be performed)
Does the patient have an intracranial aneurysmal clip
- Yes
- No
(If 'yes' - MRI scans cannot be performed)
Has the patient had surgery in the last 6 weeks
- Yes
- No
(If 'yes' - MRI scans cannot be performed)
Has the patient had a stapedectomy
- Yes
- No
(If 'yes' - upper body MRI scans cannot be performed)
Does patient have an inserted pump/device
- Yes
- No
(If 'yes' - unable to perform MRI scan in area where pump/device is located)
Please tick the below section and add today's date in lieu of a signature
Tick in lieu of signature*
Tick in lieu of signature
Today's Date*
MM slash DD slash YYYY
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Forms

Brighton Radiology has separate questions for patients and health care practitioners who are referring a patient to Brighton Radiology. At the beginning of the below form, please indicate whether you are a patient or a practitioner, so that the appropriate questions can be shown.

Patient Details

Your Health Problem

Practitioner Referral Details

Patient Details

Imaging Request Details

Referring Practitioner Details

Safety Check

Section Break

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