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- Referrer Relationship Specialists
- GP Guide to Medicare
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Home
Clinics
Our Radiologists
Access Results
Refer a Patient
Support
- Referrer Relationship Specialists
- GP Guide to Medicare
Contact

Home / Referrer – Online Referrals

Your referrals made simple

Online Referrals

South Coast Radiology offers a range of referral forms to suit your needs.

We will contact your patient to book their appointment for a time and clinic that suits them.

Complete the form below to refer directly to South Coast Radiology.

"*" indicates required fields

Referral Details

Referral Type

General Referral

Referral and/or request(s) to the doctors of South Coast Radiology

Referral Location*

Referral Date*

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 **

DD slash MM slash YYYY

Medicare No.

Phone No.*

Address

Street Address City State Post Code

Patient Email Confirmation

Please tick if your patient would like a copy of this referral sent to them.

Patient Email

Please enter patient email if they would like a copy of referral.

Investigations Required*

Clinical Notes*

Referring Doctor Details

Name*

First Last

Provider Number*

Phone No.*

Address

Street Address City State Post Code

Doctor Referral Confirmation

Please tick if you would like a copy of this referral sent to you

Email*

Additional Doctors to Receive Reports

Please add all doctors you wish to receive a copy of the report.

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.

PET-CT Imaging Request Form

Location

Nuclear Medicine Imaging Centre, Ground Floor, 147 Smith Street, Southport QLD

John Flynn Private Hospital, Level B3, Nuclear Medicine & Therapy Centre, 42 Inland Drive, Tugun

Patient name*

First Last

Date of Birth **

DD slash MM slash YYYY

Phone*

Medicare No.

Address

Street Address City State Post Code

Clinical History

Primary Site*

Histopathology*

Previous Treatment

Chemotherapy

Radiation

Surgery

Other

None

Details*

Examination Details

Please select relevant PET-CT option.*

This is a requirement of Medicare.

PET with Diagnostic CT - Standard Head to Thigh
(includes Head, Neck, Chest, Abdo, Pelvis, Thighs, ± Contrast, unless otherwise stated)

PET with Diagnostic CT - Include full lower leg
(includes Head, Neck, Chest, Abdo, Pelvis, Thighs, ± Contrast, unless otherwise stated)

PET without Diagnostic CT - Standard Head to Thigh
(includes localisation CT only)

PET without Diagnostic CT - Include full lower leg
(includes localisation CT only)

Indications for Medicare Eligible PET

Rebates only apply when referred by a Specialist. Other indications do not attract a Medicare rebate.

GA - 68

DOTATATE (GEP- NET, biochemcial evidence, surgical planning, initial staging) 61647

PSMA (initial staging) 61563

PSMA (restaging) 61564

FDG

Solitary Pulmonary Nodule 61523

Breast (Staging, locally advanced Stage III) 61524

Brain Tumour (malignant, suspected residual, recurrent) 61538

Breast (Suspected mestastatic or recurrent) 61525

Brain (performed for the diagnosis of Alzheimer's Disease) 61560

Non Small Cell Lung (staging of proven) 61529

Colorectal Carcinoma (suspected residual, metaststic, recurrent) 61541

Melanoma (suspected residual/recurrent, following initial therapy) 61553

Refractory Epilepsy 61559

Ovarian (suspected residual, metastatic, recurrent) 61565

Uterine/Cervical(Staging, FIGO stage IB2 or greater) 61571

Uterine/Cervical (recurrent) 61575

Oesophageal/GOJ (performed for the staging of proven oesophageal or GEJ carcinoma) 61577

Head & Neck (initial staging, recurrent) 61598

Head & Neck (residual) 61604

SCC (metastatic, unknown primary inv cervical nodes) 61610

Rare/Uncommon Cancer (initial staging) 61612

Rare/Uncommon Cancer (response/restaging) 61614

Lymphoma (HL&NHL) (initial staging) 61620

Lymphoma (HL&NHL) (response) 61622

Lymphoma (HL&NHL) (restaging recurrent) 61628

Lymphoma (HL&NHL) (prior to stem cell transplant) 61632

Bone/Soft Tissue Sarcoma (initial staging, excludes GIST) 61640

Bone/Soft Tissue Sarcoma (residual, recurrent, excludes GIST) 61646

Non-Medicare Eligible PET

Incurs out-of-pocket fee.

Please select relevant examination.

DOTATATE

PSMA

FDG

Other

Details

Referring Practitioner

Doctor*

First Last

Phone

Fax

Provider No.

Address

Street Address City State Post Code

PET Referring Practitioner

Please tick if you would like a copy of this referral sent to you

Referring Practitioner Email*

Date Completed*

DD slash MM slash YYYY

Send a copy of the patient report to:

Dr. First Name

Last Name

After clicking 'Submit,' please wait for your referral to be submitted. This could take up to 2 minutes.

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Need assistance? Please call our team on 1300 197 297

Trusted by Doctors, Preferred by Patients

South Coast Radiology is a major provider of advanced diagnostic imaging services and radiology education across the Gold Coast region.

A subsidiary of IDX (Integral Diagnostics).

Our Network

South Coast Radiology
Darling Downs Radiology
Mackay Radiology
The Women's Imaging Centre

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