PATIENT INFORMATION

Name:									Date of Birth: 
Sex at Birth: 
Address:								Med. No: 
Ph:
REQUEST FOR:							CLINICAL NOTES

REFERRING DOCTOR’S DETAILS:					COPIES TO:

DOCTOR’S SIGNATURE:						DATE:
RESULTS: 	☐Phone             ☐Fax             	 ☐ Urgent        ☐ Order More Referral Forms  
ULTRASOUND SCAN PREPARATION
☐  Pelvic/Renal/Early Pregnancy (up to 12 weeks) Ultrasound Drink three large glasses of water and hold the bladder till the examination finished
☐  Abdomen/Renal artery/Abdominal Aorta/Leg arteries Six hours fasting, can take medication with water

LOCATION 
Add:	471 Springvale Road, Springvale, Vic 3171 
(Next to McDonalds,  Corner of Springvale Road and Heatherton Road)
Ph:	(03) 9522 9898 	
Fax: 	(03) 9970 6411
Email 	contact@insightimaging.com.au
Opening hours:  Mon – Fri: 9am to 5pm, 
Sat: By Appointment only