E-Referral MRI

E-Referral GP MRI Form

Patient Details

DD/MM/YYYY
Gender *
(Auto calculated from DOB)
Booking Appointment

Examination

MRI Knee
MRI Head
MRI Spine
MRI Under 16 - Hip, Elbow, Wrist
MRI Prostate - Multiparametric Magnetic Resonance Imaging
Multiparametric Magnetic Resonance Imaging scan of the prostate for the detection of cancer.
Restricted to once in a 12 month period.
The patient is suspected of developing prostate cancer, due to one of the following:
• A digital rectal examination which is suspicious for prostate cancer; or
• In a person under 70 years, at least two prostate specific antigen (PSA) tests performed within an interval of 3 months are greater than 3.0 ng/ml, and the free/total PSA ratio is less than 25% or the repeat PSA exceeds 5.5 ng/ml; or
• In a person under 70 years, whose risk of developing prostate cancer based on relevant family history is at least double the average risk, at least two PSA tests performed within an interval of 1- 3 months are greater than 2.0 ng/ml, and the free/total PSA ratio is less than 25%; or
• In a person 70 years or older, at least two PSA tests performed within an interval of 1- 3 months are greater than 5.5ng/ml and the free/total PSA ratio is less than 25%.
Multiparametric Magnetic Resonance Imaging scan of the prostate for the assessment of cancer:
• the patient is under active surveillance following a confirmed diagnosis of prostate cancer by biopsy histopathology; and
• the patient is not planning or undergoing treatment for prostate cancer.

Items 63543 is applicable:
A) at the time of diagnosis of prostate cancer; and
B) 12 months following diagnosis; and
C) every third year thereafter; or
D) at any time if there is clinical concern from the specialist requesting the service.

MRI Liver
MRI Liver only payable once per patient in a twelve-month period.

item 63545 - A patient with known colorectal carcinoma with known, suspected or possible liver metastasis, for the purpose of characterisation or intervention planning, where the patient has had a mass lesion detected in the liver on previous CT scanning or ultrasound.

item 63546 - A patient with known or suspected hepatocellular carcinoma for the purposes of diagnosis or staging where the patient has pre-existing chronic liver disease, confirmed by a specialist; and has an identified hepatic lesion over 10mm in diameter; and has been assessed as having a Child-Pugh class A or B liver function.
MRI side

Clinical History

Pregnant
Is or may the patient be pregnant?
Contrast Allergy
Diabetes Metformin
Renal Disease

MRI Checklist

Pacemaker / Heart Valves
Aneurysm Clips
Cochlear / Ear Implants
Metallic foreign body to eye
Other metallic/electronic devices

Referring Practitioner

(Used to login to InteleViewer or Inteleconnect)
Copies to another referrer?
*
Please select most appropriate branch but the appointment may be at another branch.
Branch