Telehealth Online Referral PDF Conversion

APPOINTMENT DETAILS
Referral Location*
Referral Date
DD slash MM slash YYYY
REFERRAL AND/OR REQUEST(S) TO THE DOCTORS OF APEX RADIOLOGY
PATIENT DETAILS
Name*
First Last
Address*
Street Address City State / Province / Region
Medicare No. **
Phone No.*
Date of Birth
DD slash MM slash YYYY
Patient Email Confirmation
- Please tick if your patient would like a copy of this referral sent to them
Email

Please enter patient email if they would like a copy of referral.
Investigations Required*
Clinical Notes*
REFERRING DOCTOR DETAILS
Doctor*
First Last
Address*
Street Address City State / Province / Region
Provider Number*
Phone No.*
Doctors Referral submission
- Please tick if you would like a copy of this referral sent to you
Email*
Send a copy of the patient report to:
Dr. First Name Last Name
For patients who may require intravenous contrast (CT & MRI) and the patient is over 70 years old, or has suspected or known renal impairment please supply the serum levels within previous: 3 months for stable out-patient, 7 days for stable in-patient.
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APEX RADIOLOGY TELEHEALTH ONLINE REFERRAL

Apex Radiology is now accepting diagnostic imaging requests via Telehealth.

Telehealth referrals further support our local community and our doctors, while GPs, Specialists and Allied Health Professionals begin to consult patients on a remote basis, to help stop the spread of COVID-19.

Practicing safe social distancing also extends to the medical field where possible, and Apex Radiology offers the ability for doctors to send referrals safely, remotely and electronically.

Once submitted, this form is sent directly to our Bookings Centre, where your patient will be contacted to make their appointment.

APPOINTMENT DETAILS

PATIENT DETAILS

REFERRING DOCTOR DETAILS

APEX RADIOLOGY TELEHEALTH ONLINE REFERRAL

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Dr. First Name	Last Name