Sah.org.au

Your Appointment
HOURS
Monday to Friday:
Bookings: 02 9487 9840 Mobile:
Facsimile: 02 9487 9845 CARDIAC CT
www.sanradiology.com.au
MEDICARE ELIGIBLE (SPECIALIST REFERRAL ONLY)
CT Coronary Angiography
❏ The patient has stable symptoms consistent with coronary ischaemia, is at low to intermediate risk of coronary artery disease and would have been considered for coronary angiography.
❏ The patient requires exclusion of coronary artery anomaly or fistula.
❏ The patient will be undergoing non-coronary cardiac surgery.
Your doctor has recommended
that you use this imaging
NON MEDICARE ELIGIBLE
provider. However, you may
CT Coronary Angiography
choose your own imaging
provider. If you choose another
❏ Other eg. GP Referral and/or does not comply with the item number imaging provider please discuss
this with your doctor.
Calcium Score
❏ Calcium Score.
CLINICAL HISTORY
USE Sticker * Contraindication for beta blocking? Yes/No
Address:Phone/Fax:Provider Number:Doctor’s Signature: San Radiology A5 Cardiac CT Ref 017919.indd 1 PRACTICE PROCEDURE LIST
EXAMINATION PREPARATIONS FOR PATIENTS
Please note that some examinations, including interventional Dual Source Multislice CT
radiology require special preparation. Please check when Digital X-ray
Cardiac CT: No food or coffee prior to appointment, unless
Digital Mammography
diabetic. Maintain normal fluid intake. Take all regular
medications with the exceptions of Viagra, Levitra & Cialis
Image Guided Biopsy
(cease 3 days prior to scan).
Ultrasound
DIABETIC PATIENTS:
Vascular Ultrasound
Medication: If you take ANY medication to control your
diabetes, you must let us know when you make your
appointment. If special instructions are required for non ionic contrast procedures, a Radiology Nurse will contact you.
Breast MRI
Well-controlled diabetes: For examinations requiring you to
fast, book the earliest appointment possible, have a light
Interventional Radiology
breakfast and bring morning tea with you for after your test.
Dedicated San Radiology
Unstable/Insulin dependent diabetes: Continue your usual
patient parking is available
diet treatment and monitor your diabetes carefully.
IF YOU REQUIRE A CONTRAST INJECTION, PLEASE MONITOR YOUR DIABETES CAREFULLY FOR 48 HOURS AFTER YOUR EXAMINATION. CONSULT YOUR DOCTOR IF YOU BECOME CONCERNED.
PLEASE REMEMBER
TO BRING THIS
REQUEST FORM AND
YOUR PREVIOUS FILMS
TO YOUR APPOINTMENT
San Radiology A5 Cardiac CT Ref 017919.indd 2

Source: http://www.sah.org.au/assets/files/PDFs/Radiology/San%20Radiology%20Cardiac%20CT%20Referrals%20A5%20(2).pdf

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