X-Ray Referral Form Page 2

REFERRING PRACTITIONER'S DETAILS

Title (required)
 Mr Mrs Dr Other:

If you selected other in the previous question, please include the patient's title here

Name (required)

Practice (required)

Practice Address (required)

Suburb (required)

Postcode (required)

Phone (required)

Fax

Email (required)

Receive Report Method (required)
 Email Fax

Receive images method (required - Note: Additional charges apply for film)
 CD Film

Send Report to Another Practitioner (required)
 Yes No

If you answered yes to the previous question, provide details of the practitioner here

Today's Date (required)

Explained Private / Self-Pay to Patient (required)
 Yes No

Explained Online Pre-Payment Option to Patient (required)
 Yes No

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