Patient Form

Patient Information & Consent

Please complete this form before your appointment. Your information is kept confidential and used only for your care at ProScan Radiology.

Your details

Full name*

Date of birth*

Gender*

Email*

Mobile phone*

Residential address*

Medicare number

Medicare reference number

Medicare expiry (MM/YYYY)

Pension / DVA number (if applicable)

Private health fund

Emergency contact

Contact name*

Relationship*

Contact phone*

Referring doctor & appointment

Referring doctor*

Clinic / practice name

Scan / examination requested*

Appointment date (if known)

Medical history

Please answer honestly — this helps us keep you safe during your scan.

Reason for today's scan*

Current medications

Allergies (medication, contrast, latex, other)

Previous surgery or procedures

Are you (or could you be) pregnant?*

Are you currently breastfeeding?

History of kidney disease or reduced kidney function?

Diabetes?

Do you have any implants, pacemaker, aneurysm clips, or metal fragments?

Do you experience claustrophobia?

Any other conditions we should know about?

Consent & communication

I consent to the imaging examination(s) requested and understand any risks explained to me.*

If contrast is required, I consent to its administration after discussion with staff.

I consent to ProScan Radiology billing Medicare and/or my health fund on my behalf and understand any out-of-pocket fees will be explained beforehand.*

I consent to my results being shared with my referring doctor and other clinicians involved in my care.*

I'd like to receive occasional health and appointment reminders (optional).

Signature

I confirm the information provided above is true and complete to the best of my knowledge. I have read and understood the consent statements and agree to proceed with my examination at ProScan Radiology.

Sign with your mouse or finger.

16 required fields still to complete.

Privacy notice: The information you provide in this form is used solely for the purposes of your review and clinical care. It is not stored in any third-party system and is retained only within ProScan Radiology's secure clinic management system, accessible to your authorised care team.

By submitting you confirm the information is accurate. A PDF copy will be securely stored for your care team.