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 (Print and scan please)

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: 64 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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