Locations
All Branches
Clarence Valley Imaging
North Coast Radiology
Ballina
Byron Bay
Casino
Goonellabah
Lismore (North Coast Radiology)
Lismore (Northern Rivers Women’s Imaging)
Lismore (Nuclear Medicine)
Qscan (Qld)
Services
All Services
Bone Density (BMD)
DXA Body Composition
CT Scan
Dental Imaging
Interventions & Procedures
MRI
Mammography
Nuclear Medicine
Ultrasound
X-Ray
Patients
Support Centre
Appointment Bookings
Request Appointment
Upload referral
Change or Cancel Appointment
Patient Information Sheets
Understanding the Appointment Process
Patient FAQ
Billing & Payments
Medicare Information
Copies of Examinations
Patient Portal – access to images
Referrers
Online access to Results & Images (InteleConnect)
Doctor Portal – Online access to results and images
Referral Forms
E-Referrals
Diagnostic Imaging Pathways
Update/New Referrer or Practice Information
Software Downloads
Request or grant access to an examination
Medicare Guidelines
for Doctors
for Allied
About Us
Company Information
Our Radiologists
Careers
News
Contact Us
Contact Us
Compliments Suggestions Complaints
Patient Survey
Referrer Survey
Request Appointment
Change or Cancel Appointment
Careers
Locations
All Branches
Clarence Valley Imaging
North Coast Radiology
Ballina
Byron Bay
Casino
Goonellabah
Lismore (North Coast Radiology)
Lismore (Northern Rivers Women’s Imaging)
Lismore (Nuclear Medicine)
Qscan (Qld)
Services
All Services
Bone Density (BMD)
DXA Body Composition
CT Scan
Dental Imaging
Interventions & Procedures
MRI
Mammography
Nuclear Medicine
Ultrasound
X-Ray
Patients
Support Centre
Appointment Bookings
Request Appointment
Upload referral
Change or Cancel Appointment
Patient Information Sheets
Understanding the Appointment Process
Patient FAQ
Billing & Payments
Medicare Information
Copies of Examinations
Patient Portal – access to images
Referrers
Online access to Results & Images (InteleConnect)
Doctor Portal – Online access to results and images
Referral Forms
E-Referrals
Diagnostic Imaging Pathways
Update/New Referrer or Practice Information
Software Downloads
Request or grant access to an examination
Medicare Guidelines
for Doctors
for Allied
About Us
Company Information
Our Radiologists
Careers
News
Contact Us
Contact Us
Compliments Suggestions Complaints
Patient Survey
Referrer Survey
Request Appointment
Change or Cancel Appointment
Careers
E-Referral General
E-Referral Form for GPs
Patient Details
Patient Name
*
Date Of Birth
*
DD/MM/YYYY
Phone Number
*
Gender
*
Female
Male
Other
Patient Email Address
Booking Appointment
Radiology practice will call patient to arrange appointment
Patient will initiate appointment
Xray
Ankle / Foot
Chest
Foot
Hand
Knee
Pelvis
Shoulder
Spine Cervical
Spine Lumbsacral
Xray Side
Left
Right
Both
Ultrasound
Abdomen
Abdomen Vascular
Ankle / Foot
Breast
Elastography
Foot
Hand
Knee
KUB
Leg Arteries
Leg Veins
MSK with procedure
Neck
Pelvis
Pregnancy / Nuchal
Pregnancy <12 weeks
Pregnancy 12-16 weeks
Pregnancy 17-2 weeks
Scrotum
Shoulder
(Elastography only done in Sydney)
US Side
Left
Right
Both
CT
Abdomen/Pelvis
Abdomen
Angiography
Chest
Chest/Abdomen/Pelvis
Coronary Arteries
Coronary Calcium Scoring
Extremities
Facial Bones
Head
Knee
Pelvis
Petrous Bones
Sinuses
Sinuses and Brain
Soft Tissues Neck
Spine Cervical
Spine Lumbsacral
Spine Thoracic/Lumbosacral
CT Side
Left
Right
Both
Mammogram
3D Mammogram
2D Mammogram
(3D currently not available in Sydney)
Mammo Side
Left
Right
Both
Other examination (not listed above)
Is or may the patient be pregnant?
Yes
No
Contrast Allergy
Yes
No
Diabetes Metformin
Yes
No
Renal Disease
Yes
No
Creatinine level: eGFR:
Date of test
Clinical details
*
Referring Practitioner
Referrer Name
*
Practice Email
*
PACS User or RIS ID
*
(Used to login to InteleViewer or Inteleconnect)
Provider Number
*
Practice Address
Copies to another referrer?
Yes
No
Copy to:
*
I am entitled under the Health Insurance Act 1973 (Cth) to make this request
Branches
Please select most appropriate branch but the appointment may be at another branch.
North Coast Radiology
Ballina (3D Mam)
Byron Bay
Casino
Goonellabah (No CT)
St Vincents Lismore
Womens Health Lismore (3D Mam)
Clarence Valley Imaging
Grafton (3D Mam)
Maclean (No CT)
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