Alfred Hospital, Commercial Rd Melbourne VIC Australia 3004-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient information. Fill in the Patient Identification or ID Sticker and indicate if the patient is an inpatient by selecting 'Yes' or 'No'. If applicable, specify the ward.
3. Complete the medical history section by indicating if the patient is diabetic, claustrophobic, or requires an interpreter. If involved in a clinical trial, provide the trial number and contact person.
4. Fill in the patient's weight and height, along with their surname, first name, date of birth, address, and phone number for contact purposes.
5. Enter details for the referring consultant specialist including their name, provider number, and phone contact. Ensure to sign where indicated.
6. Specify where to send CDs and reports along with a fax number for report delivery. Indicate the date of referral and when results are required.
7. Select any tests required and tick relevant pre-scan diagnoses. Add any additional notes as necessary.

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