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 Pregnant / Breastfeeding eGFR Creatinine Allergies Results PreferencesUrgent Results Required? Urgent Results Required Film Film DICOM CD DICOM CD Report OnlyReport Only Download direct to my Medical Software Referrer PACS PortalReferrer PACS Portal Check here if you require an account Fax to Patient email address if copy of referral required Δ CITY XRAY MARTIN PLACE GROUND FLOOR, 32 MARTIN PLACE PH: 9251 7888 E: city@xray.com.au