E-Referral Allied

E-Referral Allied Form
Referrer *

Patient Details

DD/MM/YYYY
Gender *
Booking Appointment
Allied health practitioners cannot refer more than one of the following spinal services on the same day.
Item 58100
Item 58103
Item 58106
Other
Hips
We are able to accept requests for other radiological imaging examinations, where the Radiologist determines that “the service is clinically relevant for the treatment of the patient’s condition”. Importantly though, these examinations may not attract a Medicare rebate for the patient.
Please include Modality such as Xray or Ultrasound
Unlimited Referrals - no time restriction
Hips side
Allied health practitioners cannot refer more than one of the above spinal services on the same day.
Limited Referrals - only one of the following xrays can be performed per calendar year
Please include Modality such as Xray or Ultrasound
Examination
Body part
Side
We are able to accept requests for other radiological imaging examinations, where the Radiologist determines that “the service is clinically relevant for the treatment of the patient’s condition”. Importantly though, these examinations may not attract a Medicare rebate for the patient.
Please include Modality such as Xray or Ultrasound

Clinical History

Referring Practitioner

(Used to login to InteleViewer or Inteleconnect)
Copies to another referrer?
*
Branch *
Please select a branch. Appointment might be at another branch. No CT at Goonellabah or Maclean

Branches

North Coast Radiology
Clarence Valley Imaging
Qscan Sydney

North Coast Radiology

Phone: 1300 66 XRAY (1300 66 9729)
  • Ballina - 93 Tamar Street - 6618 2900
  • Byron Bay - 8 Bayshore Drive - 6685 2222
  • Casino - 133-145 Centre St - 6661 4400
  • Goonellabah - 799 Ballina Rd - 6625 9500
  • Northern Womens Imaging - Suite 7, St Vincent’s Hospital - 6625 9380
  • Nuclear Medicine - Suite 6, St Vincent’s Hospital - Ph 6625 9370
  • St Vincents Private Hospital - Suite 4 - 6625 9300

    • Clarence Valley Imaging

  • Grafton - 137 Fitzroy Street - 6604 2400
  • Maclean - 52 River Street - 6603 2800

    • Qscan Chatswood & Qscan Ryde

  • Chatswood - 13 Spring Street - 8423 2700
  • Ryde - Suite 1, Level 1A, 1 Pope Street - 9813 2500
    • © 2019 North Coast Radiology Group. All rights reserved.
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