Referral Form

PATIENT DETAILS	

Name: <<Patient Demographics:Full Name>>		
Address: <<Patient Demographics:Address>> <<Patient Demographics:Address Preferred City>> <<Patient Demographics:Address Preferred Postcode>>		
Date of Birth: <<Patient Demographics:DOB>>		
Medicare No: <<Patient Demographics:Medicare Number>>	DVA No: <<Patient Demographics:DVA Number>>	
Mobile No: <<Patient Demographics:Phone (Mobile)>>	Home Phone No: <<Patient Demographics:Phone (Home)>>	
Email adress: <<Patient Demographics:E-mail>>		

INVESTIGATIONS REQUIRED	

<<Investigations Required?>>

Clinical Notes:
<<Clinical Notes?>>

<<Pts >70 or renal impaired need serum levels>><<Results: 3mth for stable out-pt, 7days for stable in-pt>>
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 or 7 days for stable in-patient. Serum Level: <<Serum Level Result>>  Date of test: <<Date of serum test>>

REFERRING DOCTOR DETAILS	

Digitally Signed by Referring Doctor: <<Doctor:Name>>	Provider No: <<Doctor:Provider Number>>	
Practice Name: <<Practice:Name>>		
Practice Address: <<Practice:Address>>		
Phone No: <<Practice:Phone>>	Fax No: <<Practice:Fax>>	
		
Copy of Report to: <<Copy of report to?>>		
		
Referral Date: <<Miscellaneous:Date>>		

On Behalf of your patient, please send a copy of this referral to: 
Email: bookings@scr.com.au OR Fax: 07 5610 4030
Your patient will be contacted to arrange the requested scan(s). 
Please Note: Patient email and/or mobile is essential.