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Clinics & Services
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Resources & Support

Digital Referral Form

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Patient Details

Patient First Name*

Patient Last Name*

Patient DOB*

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Patient address information*

Street Address Address Line 2 City/Suburb State Postcode Country

Patient phone (mobile preferable)*

Patient email address*

Preferred Clinic Location

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Examination*

X-Ray

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Other imaging

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Clinical Notes*

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Is patient diabetic?*

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Is there any chance the patient may be pregnant?*

YES

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Dental imaging required?*

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Spinal imaging required?*

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Patient category

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Pension

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Referrer details

Title*

Referrer Name*

First Last

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Full AHPRA number*

Referring doctor's details

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Practice address*

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Results*

Electronic

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Telephone report

CD

Capital Connect Electronic Delivery

Healthlink

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Doctor's signature*

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Capital Radiology is a major provider of advanced diagnostic imaging services and radiology education across Victoria.

A subsidiary of IDX - Integral Diagnostics

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Acknowledgement of Country

Capital Radiology respectfully acknowledges the Wurundjeri Woi-wurrung people of the East Kulin Nation as the Traditional Owners of the land on which our clinics operate.

We recognise their continuing connection to land, waters and community, and pay our respects to Elders past and present. We extend this respect to all Aboriginal and Torres Strait Islander peoples.