HSU Clinical Imaging Referral Form

For X-Ray, Ultrasound, Ultrasound Guided Procedures and MRI

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

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Patient Information

Patient's assigned gender at birth(Required)
If aged between 12-55, is there any chance the patient may be pregnant?(Required)
Required imaging modality(Required)

Xray Details

Ultrasound Details

MRI Details

Has the patient ever had metal enter their eyes?(Required)
Is the patient claustrophobic?(Required)

Ultrasound Guided Injection Details

What injection therapy are you requesting?(Required)
Does your patient have any known allergies?(Required)
Does your patient have diabetes?(Required)
Does your patient take any blood thinning medication?(Required)
Does your patient have primary open angle glaucoma?(Required)
Does your patient have haemophilia?(Required)
Is your patient taking antibiotics?(Required)
Has your patient had an injection to the same body part within the last 3 months?(Required)
Has the patient had previous surgery to the same body part?(Required)

Submitter Details

Signature File Uploader

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