Bowral 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

HIGHLANDS XRAY & HIGHLANDS NUCLEAR IMAGING
SHOP 4, 380 BONG BONG STREET, BOWRAL
PH: 4862 2355 E: highlands@xray.com.au