IMAGING REFERRAL  

Patient Name: <<Patient Demographics:Full Name>>

Patient Address: <<Patient Demographics:Address Preferred>>
<<Patient Demographics:Address Preferred City>> <<Patient Demographics:Address Preferred Postcode>>
	
DOB: <<Patient Demographics:DOB>>
Sex:  <<Patient Demographics:Gender>>
Female patients <50 Date of LMP: <<Clinical Details:LNMP>>	

Home Phone: <<Patient Demographics:Phone (Home)>>	
Wk Phone: <<Patient Demographics:Phone (Work)>>	

Medicare Number: <<Patient Demographics:Medicare Number>>   DVA Number: <<Patient Demographics:DVA Number>>
	
* REQUIRED FIELDS   
*Mobile: <<Patient Demographics:Phone (Mobile)>>   
*Email: <<Patient Demographics:E-mail>>	
	
EXAMINATION 	

<<Type>>	
<<Examination Request Details>>

Referring Doctor: <<Doctor:Name>>
Provider Number: <<Doctor:Provider Number>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>  
Fax: <<Practice:Fax>>

Referral Date: <<Miscellaneous:Date (short)>>
Patient has consented to being contacted by I-MED Radiology to arrange appointment(s).	Instructions for referring GP:

On behalf of your patient, please send a copy of this referral to:

TelehealthQLD@i-med.com.au
or fax: 07 3624 8596

Your patient will be contacted to arrange the requested appointment(s). 
*Patient email and/or mobile are required