Submit a Referral

For urgent or emergency referrals, please also call us directly on (03) 7019 3172.

Referral Submission

Complete the form below to refer a patient. You will receive a password-protected PDF confirmation by email for your records.

⚠ Medical practitioners only.This referral form is for use by qualified referring practitioners (GPs, specialists, dentists, etc.). Patients should not submit referrals here — please ask your doctor to refer you. Submissions are digitally signed, IP-stamped and audited.
Referring Practitioner*
Practice Name*
Phone
Fax Number
Optional. If your practice receives reports by fax, include the number here.
Email Address*
Provider Number*
Patient Details
Patient Full Name*
Date of Birth*
DD slash MM slash YYYY
Patient Address*
Patient Mobile Number
Optional. Used by the clinic to contact the patient about their appointment.
Medicare Number
Optional. Include the IRN (the single digit after the main number) if known.
Patient Email (Optional)

If provided, the patient will also receive a copy of the referral receipt.
Referral Details
Imaging Type*
Select the modality required. Specify body part / details below.
Examination Requested*
Clinical Notes / Indication
Urgency
Signature *
Sign in the box below using your mouse, trackpad or finger. Tap "Clear" to start over.
Digital Signature*
By submitting this form I confirm that I am the referring practitioner named above, that the patient has consented to this referral, and that the clinical information provided is accurate. I acknowledge that my name, IP address and a timestamp will be recorded with the referral as a digital signature.
Your name, IP address and submission time will be recorded with this referral and printed on the PDF as a digital signature.

Submit a Referral

Referral Submission

Patient Details

Referral Details

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