MOBILE IMAGING REFERRAL

PATIENT DETAILS
Title: Mr / Mrs / Miss / Mstr / Other _________	Surname: _______________________________________
Date of Birth: _____ / _____ / _________		First Name: _____________________________________
Medicare number: ___________________________________
Does the patient identify as Aboriginal and/or Torres Strait Islander: 
☐ No  ☐ Yes, Aboriginal  ☐ Yes, Torres Strait Islander  ☐ Yes, both Aboriginal and Torres Strait Islander   

CONTACT DETAILS
Home No: ____________________________	Mobile No: ______________________________________
Email Address: __________________________________________________________________________  Residential Address: _____________________________________________________________________
									State: ___________	Postcode: ___________
REFERRING PRACTITIONER DETAILS
Name: ______________________________	Phone: ________________________________________
Provider No: _________________________	Fax No:  ______________________________________
Address: _______________________________________________________________________________
							  Signature: __________________  Date: ___ / ___ / _______
IMAGING REQUEST
☐  CT | Specify region  ___________________________________
☐  CXR 
☐  National Lung Cancer Screening Program (Bulk-billed) - PLEASE COMPLETE EACH SECTION BELOW
Eligibility
Does this patient meet the eligibility criteria of the National Lung Cancer Screening Program?
☐  Yes    ☐  No	
Screening required
☐  2 yearly scan for a New Participant
☐  2 yearly scan for a Returning Participant
☐  Interval scan (1,2,3, 6 or 12 month interval scan as determined in previous NLCSP LDCT report)	
History
Any previous chest CT   ☐ Yes (If yes, please provide details below)   ☐ No    ☐ Unknown

Date (if known): ___ / ___ / _______   Radiology provider/location (if known):__________________________

☐  Any family history of lung cancer in first-degree relatives (Only required for first/baseline LDCT. First-degree relatives include parents, siblings or children)

Any other cancer history   ☐ Yes (If yes, please provide details below)   ☐ No    ☐ Unknown

Details: ____________________________________________________________________________________

ADDITIONAL CLINICAL NOTES

Your personal information, including results of low dose CT scans and other CT imaging completed for the purposes of screening as part of the NLCSP, may be shared between your treating healthcare providers for the purposes of the NLCSP. For example, if you attend different radiology providers for your first low-dose CT scan and your second low-dose CT scan, the first radiology provider may disclose your low-dose CT images to the second radiology provider to facilitate comparison of the results of the two low-dose CT scans. By participating in the NLCSP, you consent to the use of your personal information by healthcare providers, specialists and radiologists, for the purposes of the program, and the disclosure and collection of your personal information between healthcare providers, specialists and radiologists for the purposes of the program.

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