RADIOLOGISTS Dr R. Nikolich MB, BS, FRANZCR, DDR. Dr Ray Blumgart MB, ChB, FFRAD. Dr Deborah Raper MB, Bch, FCR (SA), FRANZCR. Patient Details Name Date of Birth Address Telephone (H) Telephone (B) Medicare No. Referred For: Clinical Details: Results CD Referring Doctor Details Deliver Films & report return with patient Fax Report No. Doctor Signature Date Are you pregnant Yes No Is there any possibility that you are pregnant Yes No Patient Signature Please provide recent renal function test results for patients who may require contrast and fall into the following category; over 60 yrs old, suffer diabetes or hypertension or have known renal disease. IF PROGRESS PLEASE SEND PREVIOUS FILM WITH PATIENT WOLLONGONG SHELLHARBOUR CORRIMAL 383 Crown Street Wollongong, NSW 2500 Telephone: 02 4254 6900 Facsimile: 02 4227 1409 Mon - Fri: 8.00-5.00 Sat: 9.00-12.00 MRI Telephone: 02 4254 6908 Mon - Fri: 6.30-7.30 Level 1, 7 Minga Avenue Shellharbour City Centre, NSW 2529 Telephone: 02 4295 8600 Facsimile: 02 4296 3188 Mon - Fri: 8.30-5.00 Shop 3, 83 Railway Street Corrimal, NSW 2518 Telephone: 02 4268 7300 Facsimile: 02 4285 3186 Mon - Fri: 8.30-5.00 X-.Ray X-.Ray X-.Ray OPG and Dental OPG and Dental OPG and Dental Ultrasound Ultrasound Ultrasound General General General Musculoskeletal Musculoskeletal — Gynaecology Gynaecology Gynaecology Vascular/Doppler Vascular/Doppler Vascular/Doppler Guided Biopsies — Guided Biopsies C.T. Scans C.T. Scans — MRI — — Mammography Mammography — Barium Studies — — Sinogram — — Hysterosalpingogram — — (HSG) — — Guided Biopsies — — Joint Injections (including — — Facets & S-I Joints) 314212 IRG.indd 1 27/03/14 12:11 PM WOLLONGONG SHELLHARBOUR 383 Crown Street Wollongong, NSW 2500 Telephone: 02 4254 6900 Facsimile: 02 4227 1409 Level 1, 7 Minga Avenue Shellharbour City Centre, NSW 2529 Telephone: 02 4295 8600 Facsimile: 02 4296 3188 CORRIMAL Shop 3, Ronald-Glass Building 83 Railway Street Corrimal, NSW 2518 Telephone: 02 4268 7300 Facsimile: 02 4285 3186 Your doctor has recommended that you use Illawarra Radiology Group. You may choose another provider but please discuss this with your doctor first. 314212 IRG.indd 2 27/03/14 12:11 PM
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