Musculoskeletal MRI Referral Form

Please complete the below electronic form once you’ve referred a patient to Bayside Standing MRI. The form will help us assess the patient’s injury or issue and speed up the process. 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@baysidestandingmri.com.au. If you have trouble completing the form, contact us and we’ll be happy to go through it with you.

PATIENT DETAILS

Title (required)
MrMrsDrOther:

If you selected other in the previous question, please include the patient's title here

First Name (required)

Surname (required)

Birth Date (required)

Sex (required)
MaleFemaleMixed

Weight in kgs

Height in cms

Patient Street Address and Number (required)

Suburb (required)

Postcode (required)

Home Phone

Mobile Phone

Email (required)

Medicare number

Medicare expiry date

REFERRING PRACTITIONER'S DETAILS

Title (required)
MrMrsDrOther:

If you selected other in the previous question, please include your title here

Name (required)

Practice (required)

Provider Number (required)

Practice Address (required)

Suburb (required)

Postcode (required)

Phone (required)

Fax

Email (required)

Receive Report Method (required)
EmailFax

Receive images method (required - Note: Additional charges apply for film)
Online Image ViewerCDFilm

Send Report to Another Practitioner (required)
YesNo

If you answered yes to the previous question, provide details of the practitioner here

Today's Date (required)

Explained Private / Self-Pay to Patient (required)
YesNo

REGIONS TO BE SCANNED (PLEASE CHECK)

Spine: For Lumbar Spine, Cervical Spine, Lower Thoracic Spine, SI joints, please specify if Upright MRI scanning is also required

Cervical
RecumbentWeight-bearing (if possible)

Lower Thoracic
RecumbentWeight-bearing (if possible)In symptom position (if possible)

Lumbar
RecumbentWeight-bearing (if possible)In symptom position (if possible)

Sacroiliac Joints
RecumbentWeight-bearing (if possible)In symptom position (if possible)

Sacral Plexus
RecumbentWeight-bearing (if possible)In symptom position (if possible)

Upright MRI scanning also required
YesNo

Upper Extremity (All Scanned Recumbent)

Shoulder
Not suitable. We recommend the 3 Tesla scanner

Elbow
LeftRightBoth

Forearm
LeftRightBoth

Wrist
LeftRightBoth

Hand
LeftRightBoth

Finger/Thumb
LeftRightBoth

Other (please provide details)

Lower Extremity - Scanned recumbent, except for knees; please specify if upright knee MRI scanning is also required

Hip
Not suitable. We recommend the 3 Tesla scanner

Knee
LeftRightBoth

Calf/Tibia
LeftRightBoth

Achilles
LeftRightBoth

Ankle/Heel
LeftRightBoth

Midfoot
LeftRightBoth

Forefoot
LeftRightBoth

Upright Knee MRI scanning also required
YesNo

Urgency

Urgency (required)
UrgentNon-urgent

Relevant previous imaging

Relevant Previous Imaging (required)
NoneFilmDigital

SAFETY CHECK

Does the patient have a cardiac pacemaker / defibrillator? If yes, we are unable to proceed with scan (required)
YesNo

Does the patient have a cochlear implant or neurostimulator? If yes, we are unable to proceed with scan (required)
YesNo

Does the patient have a programmable, magnetically adjustable ventriculoperitoneal shunt? If yes, we are unable to proceed with scan (required)
YesNo

Does the patient have an intracranial aneurysmal clip? If yes, we are unable to proceed with scan (required)
YesNo

Has the patient had surgery in the last 6 weeks? If yes, we are unable to proceed with scan (required)
YesNo

Has the patient had a stapedectomy? If yes, we are unable to perform upper body scans (required)
YesNo

Does the patient have an inserted pump / device? If yes, we are unable to perform scans in the area of the pump / implant / device (required)
YesNo

CLINICAL DETAILS / QUERIES

Please add any additional details or questions here. The form is then completed and can be submitted to send the details to Bayside Standing MRI. A copy of the details will also be emailed to you