Referrer & Contact Details:

Referrer Name: *

Mobile Number: *

Contact Name & Number (For appointment confirmation) *

Email Contact (If applicable)

Patient Details:

Patient Full Name: *

DOB: *

Safety & Risk Assessment:

Jones Radiology cannot guarantee onsite nursing care of patients, the hospital/care facility may need to provide nursing supervision. You are required to supply a nurse escort for any of the following presentations.

Patient is uncooperative, incoherent, unresponsive or cognitively impaired	Nurse escort required
Health is unstable	Nurse escort required
Unable to consume food and water unassisted	Nurse escort required
Unable to attend toilet unassisted	Nurse escort required
Intravenous drips, infusions, drains	Nurse escort required
SAAS, Private Ambulance service transport	Nurse escort required
Requirement to administer medication during visit	Nurse escort required

I confirm that our facility will provide the support of an enrolled nurse to attend with the patient if they meet any of the criteria listed above. Please note that for PET appointments, the nurse escort must not be pregnant. *

Transport:

How will the patient be travelling to their appointment? *

Private CarSAASActFasOther

Your facility is required to organise a responsible person to travel with and care for the patient for the duration of their transit/visit

ActFas perform their own risk assessment and will not transport high-risk patients. If ActFas have approved transport, a nurse escort is not required.

Please specify travel type: *

Resus Status:

Please provide an Advanced Care Directive or Hospital Documentation with the patient on the day.

Please tick the appropriate answer *

For ResusNot for Resus

Allergies & Precautions:

List allergies and/or precautions (inc. COVID, MRSA, VRE etc): *

Critical & Unexpected Findings Pathways:

Please provide detailed post-imaging requirements below: *

Patient returning to original site via original transport Patient being transferred to other facility for treatment/managementOther

Please specify: *

Mobility Status:

Additional Comments/Notes:

Please provide any additional information that applies:

Preferred Clinic:

We will endeavour to accommodate the preferred clinic however clinic options may be limited due to patient mobility and care status.

Please select the preferred appointment location:

Authorisation:

I confirm that our facility will: *

Ensure patient preparation is followed appropriate for the Jones Radiology procedure. Follow the procedure information guidelines where provided (i.e. PET).Provide sufficient Oxygen supply to last two hours for patients on Oxygen therapy if attending non-hospital Jones Radiology clinics i.e. Kurralta Park – Tennyson Centre.Provide food for the patient. Jones Radiology is unable to cater for food requirements for the patient.If pain is an issue, ensure adequate analgesia is administered PRIOR to their appointment. Please note that Jones Radiology does not keep medication or drugs of dependence on site. Please provide any medications required to the escorting nurse for the appointment. Jones Radiology nursing staff will not take responsibility for these medications and will only administer medication charted by the Radiologist.Provide bedside notes to accompany the patient to their appointment. If travelling from another healthcare facility to Jones Radiology, please ensure all appropriate documentation accompanies the patient to their appointment to allow us to provide appropriate/adequate care for your patient.Provide advanced care directive evidence when appropriate.Contact the clinic and ask to speak to a site nurse if I have any concerns about this form or patient condition. An updated form can be provided if the patients condition varies before their appointment.Disclaimer – I acknowledge that the above information is correct to the best of my knowledge. I have read and understood the contents of this form.

Name (completed by): *

Signature: *

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Date: *

Please upload a copy of the referral *

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