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Martin Place Online Referral Form

Home » Martin Place Online Referral Form

Radiology Request Form

Diagnostic Imaging, Interventional Procedures +/- Consultation

Billing(Required)

Private

Medicare/DVA (Bulk Bill)

Workers Comp/Third Party

(Please attach Approval Form)

Medicare/DVA Number(Required)

Patient Name

Date(Required)

Day

Month

Year

Gender(Required)

Male

Female

Unknown/Other

Exam Requested(Required)

Clinical Notes(Required)

Referrer Name(Required)

Provider Number(Required)

Practice Details(Required)

Copy to

Signature(Required)

Date Signed(Required)

Signed Date

Day

Month

Year

Pregnant / Breastfeeding

eGFR

Creatinine

Allergies

Results Preferences

Urgent Results Required?

Urgent Results Required

Film

DICOM CD

Report Only

Download direct to my Medical Software

Referrer PACS Portal

Check here if you require an account

Fax to

Patient email address if copy of referral required

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CITY XRAY MARTIN PLACE
GROUND FLOOR, 32 MARTIN PLACE
PH: 9251 7888 E: city@xray.com.au

Booking Request

First Name*
Last Name*
Phone Number*
Email Address*
Appointment Date*
DD slash MM slash YYYY

Appointment Date
Appointment Time*
Appointment Location*
Message*
Comments
This field is for validation purposes and should be left unchanged.

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Enquiry Request

First Name*
Last Name*
Phone Number*
Email Address*
Message*
Phone
This field is for validation purposes and should be left unchanged.

Δ

Locations

City XRAY - Martin Place
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Georges River - Revesby
IMI - Wollongong

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SMI - Nowra
Beaches XRAY - Dee Why
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Site Last Updated: 2:39 pm on February 15, 2021