Healthcare Imaging Services Pty Ltd ABN: 65 080 595 937 HISNREF???? - 12/15

Your doctor has recommended you use Canberra Diagnostic Imaging. This request is valid at other Radiology providers.

Canberra Diagnostic ImagingNational Capital Private HospitalLevel 1, Corner Gilmore Crescent & Hospital Road, Garran ACT 2605Ph 02 6195 8900 Fax: 02 6195 8999

Dr Karen Falk FRANZCRA/Prof Barry Elison FRACPDr Niri Ganeshan FRANZCR

Canberra Diagnostic ImagingNational Capital Private HospitalLevel 1, Corner Gilmore Crescent & Hospital Road, Garran ACT 2605Ph 02 6195 8900 Fax: 02 6195 8999

Patient Privacy Declaration We are bound by the Privacy Act 1988 (Cth) and other state and territory laws that regulate personal information and health information. Details on what information we collect, use, store and disclose and your rights to access and update that information is contained in the Healthcare Imaging Services privacy policy. I hereby consent to the collecting, using, storing and disclosing of my personal information and health information in accordance with the Privacy Policy.

Signature:_____________________________________________ Date: ___________________

Patient appointment Payment at time of service is required

Centre

Date / / Time :

PLEASE BRING ANY RELEVANT PREVIOUS X-RAYS FOR COMPARISON

Patient preparation instructions• Ultrasound Upper Abdomen Nothing to eat or drink for 8 hours prior to the test.

Specific instructions will be given at time of makingappointment for the following examinations:• CT Scanning • Women’s Imaging• DSA • MRI• Interventional Procedures • Nuclear Medicine• Ultrasound

MRI 3T General X-Ray Women’s Imaging

Low Dose CT 320 Ultrasound Nuclear Medicine

Cardiac Imaging Interventional Procedures Sports Imaging

HINDMARSH

DRIVE

PALMER STREETPALMER STREET

GAU

NT PLACE

KITCHENER STREET

YAMBA DRIVE

HOSPITAL ROAD HOSPITAL ROAD

BATESON ROAD

DANN CLOSE

GILMORE C

RESCEN

T

National Capital

Private Hospital

SouthernCar Park

TO WODEN

TO FYSHWICKTO GARRAN SHOPS

TO CITY

Canberra Diagnostic

Imaging

H

P

Yamba DriveCar ParkP

Centenary Hospitalfor Women and Children

EmergencyDepartment

Main Entry

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