Wollongong 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

ILLAWARRA MEDICAL IMAGING DAPTO
PICCADILLY SQUARE, 341 CROWN ST, WOLLONGONG
PH: 4222 0022 E: imi@xray.com.au