Diagnostic Imaging E-Request

Marina is dedicated to supporting the medical community and patients throughout these trying times. Referrers can send their patients’ radiology requests electronically by filling the form below, integrating seamlessly with Telehealth. Once received, our staff will call the patient to schedule their appointment. Alternatively, if you already have a referral that you would like to upload, please click here.

* Indicates mandatory fields

PATIENT INFORMATION

First Name:*

Family Name:*

Date of Birth:*

Gender:

Patient Contact Number:*

Email:*

Street:*

Suburb:*

State:*

Postcode:*

Examination Requested:*

Clinical Details:*

REFERRER DETAILS

Name:*

Email:

AHPRA:*

Contact Number:

Provider No:*

Clinic Name:

Street:*

Suburb:*

State:*

Postcode:*

Signature:

Name:

Date:*

I am entitled under the Health Insurance Act 1973 (Cth) to make this request

Urgent result required (Contact number of Referring Practitioner required)

If you have any further questions or concerns, please do not hesitate to contact us on 1300 0 XRAYS

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PLEASE NOTE:
ALL BRANCHES
ARE CLOSED FOR QUEEN’S BIRTHDAY
(JUNE 8TH)