Health Professionals may use this form to submit referrals to us. Please fax to 2780988  or  call us on Ph: 2788994 and we will send you a referral pad. Please ensure all fields are completed to ensure prompt processing of the referral. We will contact patients quickly to make an appointment convenient to them.

Pre - Screening checklist.

Please check and note any of the following which may prevent your patient having their scan: Pregnancy, Cardiac Pacemaker or other electronic implants, Previous metal in eye, Claustrophobia

REFERRAL FORM  Fax to: 2780988  Patient Details :    NHI #           DOB Title Mr Mrs Ms Other Last Name First Address: Street   Suburb City       Phone: Home Mobile Work  ACC#               MRI     CT      BONE DENSITY      US      INTERVENTIONAL   OTHER (BIOPSY ETC)  Joint Select Knee Ankle Hip Shoulder Elbow Wrist   Extremity Select Thigh Leg Foot Arm Forearm Axilla Hand   Spine Select Lumbar Cervical Thoracic Whole    Brain  Breast  Heart  CTHigh Res Lungs  IAM  Abdomen  Angiography  CT Colonography  Neck  Chest  Whole Body Turbo Stir  Orbits  Pituitary  Pelvis  MRCP  Sinuses  Temporal Bone  Other (specify)           Clinical Details:   Referrer: Name Medical Registration # Phone                              Address                                  Films    CD   Give to Patient   Send