Patient Appointment Request

1Referral

2Appointment

3Your Details

4Submit

Your Referral

You need to provide a referral from your practitioner to have imaging done.(Required)

Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf, Max. file size: 50 MB, Max. files: 4.

We will need to contact you to discuss your appointment, so make sure you keep an eye on your email or phone. You’ll need to bring your referral with you on the day.

Cards(Required)

Services Australia Pension Card

Services Australia HCC (Health Care Card)

ACT/NSW Seniors Card

DVA Card - GOLD

DVA Card - WHITE

ACT/NSW Full Time Tertiary Student Card (Including AIS)

Not Applicable

To confirm your billing, we need to know if you have any card entitlements.

DVA Number(Required)

Please provide your DVA number to assist us in making this booking

DVA White Card Accepted Condition(Required)

Please provide your accepted condition(s) to assist us in making this booking

Is this Workers' Compensation, CTP or MAI?(Required)

Yes

Claim Number

Please provide your case number

Case Manager

Please provide your case manager and contact number

Your Details

Name (first/last)(Required)

First Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Confirm Email(Required)

Your Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medicare Card(Required)

I have a valid Medicare card (please bring this to your appointment)

I DO NOT have a valid Medicare card

Contact(Required)

I confirm that I am happy to be contacted via either phone or email in regard to this request

Canberra Imaging Group

Your Referral

We will need to contact you to discuss your appointment, so make sure you keep an eye on your email or phone. You’ll need to bring your referral with you on the day.

Appointment Details

Please use this form: Goulburn MRI Bookings

Date & Time

Your Details

Search form

Search form

Canberra Imaging Group

Patient Appointment Request

Your Referral

We will need to contact you to discuss your appointment, so make sure you keep an eye on your email or phone. You’ll need to bring your referral with you on the day.

Appointment Details

Please use this form: Goulburn MRI Bookings

Date & Time

Your Details