Import to Apex Radiology PACS

1300 668 957

Study Details - Patient Full Name*
First Last
Patient Date of Birth*
DD slash MM slash YYYY
Study Required - Body Region*
Study Date (if known)
DD slash MM slash YYYY
Multiple Patient Request
Patient Name Date of Birth Study Required
Consent
Report Required (fax only)
Fax Number
AUTHORISATION - By making this request I acknowledge that these images are required as part of the ongoing clincal management for this patient and will be managed in accordance with the Privacy Act 1988. Your name:*
First Last
Contact Number*
Email*
Hospital*
Department*
Date*
DD slash MM slash YYYY
CAPTCHA

Patient Name	Date of Birth	Study Required