Locations
All Branches
Clarence Valley Imaging
North Coast Radiology
Ballina
Byron Bay
Casino
Goonellabah
Lismore (North Coast Radiology)
Lismore (Northern Rivers Women’s Imaging)
Lismore (Nuclear Medicine)
Qscan (Qld)
Services
All Services
Bone Density (BMD)
DXA Body Composition
CT Scan
Dental Imaging
Interventions & Procedures
MRI
Mammography
Nuclear Medicine
Ultrasound
X-Ray
Patients
Support Centre
Appointment Bookings
Request Appointment
Upload referral
Change or Cancel Appointment
Patient Information Sheets
Understanding the Appointment Process
Patient FAQ
Billing & Payments
Medicare Information
Copies of Examinations
Patient Portal – access to images
Referrers
Online access to Results & Images (InteleConnect)
Doctor Portal – Online access to results and images
Referral Forms
E-Referrals
Diagnostic Imaging Pathways
Update/New Referrer or Practice Information
Software Downloads
Request or grant access to an examination
Medicare Guidelines
for Doctors
for Allied
About Us
Company Information
Our Radiologists
Careers
News
Contact Us
Contact Us
Compliments Suggestions Complaints
Patient Survey
Referrer Survey
Request Appointment
Change or Cancel Appointment
Careers
Locations
All Branches
Clarence Valley Imaging
North Coast Radiology
Ballina
Byron Bay
Casino
Goonellabah
Lismore (North Coast Radiology)
Lismore (Northern Rivers Women’s Imaging)
Lismore (Nuclear Medicine)
Qscan (Qld)
Services
All Services
Bone Density (BMD)
DXA Body Composition
CT Scan
Dental Imaging
Interventions & Procedures
MRI
Mammography
Nuclear Medicine
Ultrasound
X-Ray
Patients
Support Centre
Appointment Bookings
Request Appointment
Upload referral
Change or Cancel Appointment
Patient Information Sheets
Understanding the Appointment Process
Patient FAQ
Billing & Payments
Medicare Information
Copies of Examinations
Patient Portal – access to images
Referrers
Online access to Results & Images (InteleConnect)
Doctor Portal – Online access to results and images
Referral Forms
E-Referrals
Diagnostic Imaging Pathways
Update/New Referrer or Practice Information
Software Downloads
Request or grant access to an examination
Medicare Guidelines
for Doctors
for Allied
About Us
Company Information
Our Radiologists
Careers
News
Contact Us
Contact Us
Compliments Suggestions Complaints
Patient Survey
Referrer Survey
Request Appointment
Change or Cancel Appointment
Careers
E-Referral Nuclear Medicine
E-Referral NM Form
Patient Details
Patient Name
*
Date Of Birth
*
DD/MM/YYYY
Phone Number
*
Gender
*
Female
Male
Other
Patient Email Address
Booking Appointment
Radiology practice will call patient to arrange appointment
Patient will initiate appointment
Nuclear Medicine request
Bone scan +/- SPECT CT
Brain perfusion SPECT/CT
Colonic transit study
Gallium scan
Gastric emptying study
Gated heart pool scan (GHPS)
GIT blood loss study
Heptobiliary scan/HIDA
Lymphoscintigraphy – Breast/melanoma
Meckel's study
Myocardial perfusion
Parathyroid scan
RBC liver scan
Renal parenchymal (DMSA)
Renal perfusion (MAG3/DTPA) – Captopril
Renal perfusion (MAG3/DTPA) – Lasix
Renal perfusion GFR (DTPA)
Thyroid iodine therapy I-131
Thyroid scan
V/Q lung scan
White blood cell scan
Exam details
Clinical details
Referring Practitioner
Referrer Name
*
Practice Email
*
PACS User or RIS ID
*
(Used to login to InteleViewer or Inteleconnect)
Provider Number
*
Practice Address
Copies to another referrer?
Yes
No
Copy to:
*
I am entitled under the Health Insurance Act 1973 (Cth) to make this request
Submit
If you are human, leave this field blank.
Δ
