Request for Imaging Form (e-Referral)

Practitioners can refer patients using our online platform. Referrals can be:

Here are copies of our referrals in a PDF that can be filled in (or simply use the online form below):

BASIC REFERRAL	PET REFERRAL

Please use the below form to request imaging for your patient. Our bookings staff will contact the patient to arrange an appointment.

Patient Details
Patient Name*
First Last
Date of Birth

Day
Month
Year
Preferred Phone Contact*
Patient Email (a copy will be sent to the patient)
Exam Requested*
Clinical Notes/Comments/Special Requirements/Urgency
Referring Practitioner Details
Practitioner Name*
First Last
Practitioner Email (a copy will be sent to you)
Provider Number*
Practice Name & Suburb
Practitioner Phone
CC Doctor

Please enter as much details as possible.
Referral Upload
Max. file size: 2 MB.
Please attached a referral if you have one available
Signature
Name
Date*

DD
MM
YYYY
- I am entitled under the Health Insurance ACT 1973 to make this request
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