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Arabic
Hindi / Punjab
Find a Clinic
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Resources & Support
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e-referral options
Allied Health Referrals
IT Support
Order Referral Pads
Digital Referral Form
Downloadable Resources
Services
Bone Densitometry
CT (Computed Tomography)
CTCA (Coronary Angiography)
Dental Imaging (OPG)
Echocardiography
General X-Ray
Interventional Procedures
Ultrasound
Magnetic Resonance Imaging (MRI)
Mammography
Nuclear Medicine
Injections for Osteoarthritis
Lung Screening
Patient Information
Fees & Billing
Feedback
Workers Compensation
Overseas Patients
Frequently Asked Questions
WA Patient Portal
About
Careers
Contact Us
Patient Updates
Our Technology
Research Partners
Christmas Hours
Request Appointment
Find a Clinic
Medical Liaison Officers
Resources & Support
Access Patient Images
e-referral options
Allied Health Referrals
IT Support
Order Referral Pads
Digital Referral Form
Downloadable Resources
Services
Bone Densitometry
CT (Computed Tomography)
CTCA (Coronary Angiography)
Dental Imaging (OPG)
Echocardiography
General X-Ray
Interventional Procedures
Ultrasound
Magnetic Resonance Imaging (MRI)
Mammography
Nuclear Medicine
Injections for Osteoarthritis
Lung Screening
Patient Information
Fees & Billing
Feedback
Workers Compensation
Overseas Patients
Frequently Asked Questions
WA Patient Portal
About
Careers
Contact Us
Patient Updates
Our Technology
Research Partners
Christmas Hours
English
English
Mandarin
Vietnamese
Greek
Arabic
Hindi / Punjab
Digital Referral Form
State
Please note: Capital Radiology only offers services within Victoria and Western Australia
VIC
WA
Patient Details
Full Name
Date of Birth
Street
Suburb
Phone (mobile preferable)
Email Address
Medicare number
Preferred clinic location
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Examination
Bone Densitometry
CT Angiography
CT Scan
CT Coronary Angiography
Dental Imaging
Echocardiography
Mammogram
MRI
Nuclear Medicine
Stress echocardiography
X-Ray
Ultrasound
Other
Name of Other Examination Type
Clinical Notes
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Patient History
Is the Patient Diabetic?
Yes
No
Renal Function: eGFR
Required if > 65 yo HT, DM or known renal disease
Yes
No
Is there any chance the patient may be pregnant?
Yes
No
Patient category
PTE
VET/Aff
W/C
TAC
Pension
Other
Name of your Other Patient Category
Additional information for Radiologist
Referrer Details
Doctor's name
Provider number
Referring doctor's details
Please include any other relevant details
Street Address
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State
Results
Electronic Report
Films to Patient
Telephone report
CD
Capital Connect Electronic Delivery
Healthlink
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