Skip to main content
Search form
Call us
(02) 9170 4500
Book an appointment
Menu
Home
About Us
Quality Care
Image Archiving
Radiology
Nuclear Medicine
Patient Information on Healthcare Associated Infections
Billing & Fees
Privacy Policy
Services
Our Doctors
Referrers
Online Request
Intelerad Login
Inteleviewer PACS Access
Order Pad Request
Printable & Electronically Fillable Requests
Medicare Indications
MRI Medicare Rebate
Useful References
PMS Request Templates
Health Hub
Contact Us
Careers
Job Opportunities
Quick Enquiry
Staff Login
Home
Referrers
Electronic Imaging Request
Electronic Imaging Request
Patient:
*
Gender
Date of Birth (example 28/01/1975)
*
Patient Contact Number
*
Patient Email
Patient Address
*
Clinical Details:
*
Examination:
*
If female and of child bearing age, please indicate if patient may be pregnant:
Yes
No
Contrast Allergy:
Yes
No
Renal Disease:
Yes
No
Diabetes Metformin treatment:
Yes
No
Referring Practitioner:
*
Referrer Email
AHPRA Number:
*
Provider Number:
Requester Number:
Practice Address:
Practice Name:
Practice Contact Number:
Cc Doctor:
CC Referrer Email
ccProvider Number:
ccPractice Name:
ccPractice Address:
Signature:
*
Date:
I am entitled under the Health Insurance Act 1973 (Cth) to make this request
*
I am entitled under the health insurance act 1973 (Cth) to make this request
Urgent result required (Contact number of Referring Practitioner required)
Urgent result required (Contact number of Referring Practitioner required)
