E-Referral General

E-Referral Form for GPs

Patient Details

DD/MM/YYYY
Gender *
Booking Appointment
Xray
Xray Side
Ultrasound
(Elastography only done in Sydney)
US Side
CT
CT Side
Mammogram
(3D currently not available in Sydney)
Mammo Side
Is or may the patient be pregnant?
Contrast Allergy
Diabetes Metformin
Renal Disease

Referring Practitioner

(Used to login to InteleViewer or Inteleconnect)
Copies to another referrer?
*

Branches

Please select most appropriate branch but the appointment may be at another branch.
North Coast Radiology
Clarence Valley Imaging
Qscan Sydney