Appointment Request Form Goulburn MRI

PLEASE NOTE: This form is for MRI in Goulburn ONLY.

For all other bookings: www.canberraimaging.com.au/patient-appointment-request-form/

Personal Details

Name*

Given Name Surname

Date of Birth*

Email*

Re-Enter Email*

Email appointment details:*

I am happy to be contacted via either phone or email in regard to this request
I am NOT happy to be contacted via email

If you have agreed to be emailed in regard to this appointment, please ensure you check your junk folder in your email for our communication.

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Preferred Phone Contact*

Secondary Phone Contact

Are you pregnant?*

Yes
No

Are you breastfeeding?*

Yes
No

Are you diabetic?*

Yes
No

Do you have a Contrast (X-Ray Dye) Allergy?*

Yes
No

Workers' Compensation or CTP?*

Yes
No

Workers Compensation and CTP additional questions

Claim Number*

Please enter your claim number

Case Manager

Please give us your case manager name

Case Manager Contact Number

Please give us the contact number for your case manager

Card Entitlements

None
DVA Gold
DVA White
Centrelink Pension Card
Centrelink Healthcare Card
Full-time Tertiary Student Card
AIS Full-time Student Card
Other Entitlements Card

Mobility Assistance:

Mobility assistance required

Appointment Details

Please indicate a Priority for this appointment request*

We will do our best to accommodate your priority request.

Comment: (i.e. Exam Details, Special Requirements, Urgency, Booking Preference (such as a preferred day of the week etc))

Referral Upload

Drop files here or

Max. file size: 64 MB.

Please upload your referral to assist us in streamlining our service to you. If you are using an iPhone, use the Notes App to scan a document or consider downloading the Adobe Scan App on your smartphone. Please note this may take some time to upload, please be patient.

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