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