IMAGING	REQUEST		
Dr A Gutmann 
Dr G Geier 
 
Date: <FormattedDate>

PATIENT DETAILS:
Title: <PtTitle>			Surname: <PtSurname>		First Name: <PtFirstName>
DOB: <PtDoB>			Age: <PtAge> 			
Medicare No.:  <PtMCNo> <PtMCLine> 	DVA No.: <PtDVANo> <PtDVACard>
Street: <PtAddress>		Home Phone:	<PtPhoneH>	Mobile: <PtPhoneMob>

SERVICE/S REQUIRED:
General X-ray	<General X-ray>	Pain Management	<Pain Management>	
CT	<CT>	Ultrasound	<Ultrasound>	
Dental Radiography	<Dental Radiography>	Musculoskeletal	<Musculoskeletal>	
Bone Densitometry	<Bone Densitometry>	Nuclear Medicine	<Nuclear Medicine>	
Mammography	<Mammography>	Vascular (Mon & Alt Fri)	<Vascular>	

REGION OF EXAM: 
<Region of Exam:>

CLINICAL NOTES:
<Clinical Notes:>

REFERRING DOCTOR / ALLIED HEALTH PROFESSIONAL:
Name: <DrName>
Provider Number: <DrProviderNo>
Practice Name: <Practice>
Address:<DrAddress>
Phone No: <DrPhone>	
Fax No: <DrFax>
Copy to: <Copy To>

Referrer’s Signature: 	__________________________________Date: <TodaysDate>		ABN 25857 470 544

Our practice is predominantly a bulk billing practice for most services with the exception of some ultrasound, U/S Interventional services and nuchal translucency scans where a small gap will be charged for non-concessional patients. Pensioners/Health Care Card holders and under 18’s will be bulk billed for ALL services.   Clinical notes on the request form must meet the criteria devised by Medicare. Please contact our receptionists for any queries.