IMAGING	REQUEST		
Dr A Gutmann 
Dr G Geier 
 
Date: <<Miscellaneous:Date (short)>>

PATIENT DETAILS:
Title: <<Patient Demographics:Title>>  Surname: <<Patient Demographics:Surname>>	 First Name: <<Patient Demographics:First Name>>     DOB: <<Patient Demographics:DOB>>     Age: <<Patient Demographics:Age>>			Medicare No.:  <<Patient Demographics:Medicare Number>>	DVA No.: <<Patient Demographics:DVA Number>>
Street: <<Patient Demographics:Full Address>>	Home Phone:	<<Patient Demographics:Phone (Home)>>   Mobile: <<Patient Demographics:Phone (Mobile)>>

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: <<Doctor:Name>>
Provider Number: <<Doctor:Provider Number>>
Practice Name: <<Practice:Name>>
Address:<<Practice:Address>>
Phone No: <<Practice:Phone>>
Fax No: <<Practice:Fax>>
Copy to: <<Copy To>>

Referrer’s Signature: 	__________________________________Date: <<Miscellaneous:Date (short)>>	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.