Telehealth Online Referral PDF Conversion | South Coast Radiology | Radiology Services

APPOINTMENT DETAILS
Referral Location
Referral Date
Date Format: DD slash MM slash YYYY
REFERRAL AND/OR REQUEST(S) TO THE DOCTORS OF SOUTH COAST RADIOLOGY
PATIENT DETAILS
Name*
First Last
Date of Birth **
Date Format: DD slash MM slash YYYY
Phone No.*
Address
Street Address City State / Province / Region
Medicare No.
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
Provider Number*
Phone No.*
Address
Street Address City State / Province / Region
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.
Your doctor has recommended you use South Coast Radiology. You may choose another provider, but please discuss this with your doctor first.
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SOUTH COAST RADIOLOGY TELEHEALTH ONLINE REFERRAL

South Coast 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 South Coast 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

SOUTH COAST RADIOLOGY TELEHEALTH ONLINE REFERRAL

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Secure Telehealth Referral Upload

Secure Telehealth Referral Upload

Dr. First Name	Last Name