Request An Appointment

Your online booking request is subject to confirmation by our staff who will contact the patient within 4 hours of receiving the referral.

Patient's Surname:

Patient's First Name:

Patient's Contact Number:

Patient's Email:

Examination Required:

DIAGNOSTIC IMAGING

MRI
CT
Ultrasound
X-ray

DIAGNOSTIC IMAGING :: For Diagnostic Imaging please select from the list

NOTES: Body Region Required

NOTES: Body Region Required :: Please describe body region or area to be examined

INTERVENTIONAL RADIOLOGY

Procedure Required & Notes:

Procedure Required & Notes: :: Please include any relevant notes that may assist

Referring Clinician's Name

Referring Clinician's Contact Number:

Referring Clinician's Contact Number: :: Please include contact phone number including area code

Preferred Times for Appointment

Morning: 9am -12pm
Middle of the day: 12pm-2pm
Afternoon: 2pm-5pm
Anytime

Preferred Day

Preferred Day :: Select the date from the calendar

Additional Notes:

ANTI-SPAM CAPTCHA - Type the text shown in the image:

ANTI-SPAM CAPTCHA - Type the text shown in the image: :: Please type the text as shown

Name:	*
Username:	*
E-mail:	*
Password:	*
Verify Password:	*
Fields marked with an asterisk (*) are required.