E-Referrals including Form

Below are list of E-Referral PDF forms. They will allow you to create a referral and email it direct to us. Once received we will contact the patient to arrange an appointment.


Please save to your desktop and open in Acrobat or similar. Will not work in some browsers.


North Coast Radiology

General Imaging Request E-Form

MRI GP E-form

MRI Liver E-form

MRI Multiparametric Prostate E-form

BMD Request E-form

Allied Imaging Request E-Form

Chiro Imaging Request E-Form

Dental Request E-form


Clarence Valley Imaging

MRI GP E-form

BMD Request E-form

Dental Request E-form


What does this mean for you and your patients?


  • No more urgent calls to your practice requesting reprints of referrals as we would have received it electronically direct from your practice.
  • Radiology referrals generated during a Telehealth consult can be emailed directly to North Coast Radiology and the patient.
  • Hyperlinks to extra information for each modality, including up to date Medicare criteria and Imaging Pathways.
  • Google maps links for each NCR branch.
  • Patients will not have to initiate the booking process which will mean greater follow up and completion of requested investigations for clinical correlation.
  • Less on hold wait time for both patients and referrers.
  • Efficient, accurate booking and preparation process as NCR will have the information required, without relying on the patient to interpret medical terminology.
  • Once the appointment has been initiated by our clerical staff, the patient  will be sent a copy of the referral with the appointment date & time, branch details and any preparation.

Upload & Send Scanned Referral

If you already have a referral it can be uploaded here.

Upload referral
Please enter your full name here
Region *
File Upload *

Maximum file size: 10MB


E-Referral GP MRI Form

E-Referral GP MRI Form

Patient Details

Gender *
(Auto calculated from DOB)
Booking Appointment


MRI Knee
MRI Head
MRI Spine
MRI Under 16 - Hip, Elbow, Wrist
MRI side

Clinical History

Is or may the patient be pregnant?
Contrast Allergy
Diabetes Metformin
Renal Disease

MRI Checklist

Pacemaker / Heart Valves
Aneurysm Clips
Cochlear / Ear Implants
Metallic foreign body to eye
Other metallic/electronic devices

Referring Practitioner

(Used to login to InteleViewer or Inteleconnect)
Copies to another referrer?
Please select most appropriate branch but the appointment may be at another branch.
Branch *