Haymarket Online Referral Form

Radiology Request Form

Diagnostic Imaging, Interventional Procedures +/- Consultation

Billing(Required)
(Please attach Approval Form)
Date(Required)
Gender(Required)
Date Signed(Required)
Signed Date
Pregnant / Breastfeeding

Results Preferences


Urgent Results Required?
Film
DICOM CD
Report Only
Report Only
Referrer PACS Portal
Referrer PACS Portal

CITY XRAY HAYMARKET
HSBC BUILDING, LEVEL 2, 724 GEORGE STREET, HAYMARKET
PH: 9251 7888 E: haymarket@xray.com.au