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Home
About Us
Who We Are
Our Team
New Patients
Medical Consultations with Dr Hayter
Nutrition Consultations with Sonya Cacciotti
Advisory Consultations with Dr Hayter
Client Information
Making an Appointment
Scripts and Referrals
Obtaining Test Results
Reminder System
Test Requests
Contacting Our Practitioners
Telehealth Appointments
Payment
Cancellation Policy
Fee Structure
Make an Appointment
Webinars
Shop
Contact
Imaging Request
"
*
" indicates required fields
Patient Details
First name:
*
Last name:
*
Date of Birth:
*
DD slash MM slash YYYY
Please enter your date of birth in the format DD/MM/YYYY
Mobile Phone:
*
Email:
*
How would you like this repeat prescription delivered?
*
I would like the request emailed to the email address on my file – $25
I would like a printed referral (pick up only) – $25
Request Details
Describe the symptoms or medical issues that have led to this request (one single topic):
*
How long have you had these symptoms?
Specific imaging requested (if applicable)
*
X-ray
Ultrasound
MRI
Don’t know
Preferred radiology provider:
Important Information
This service is available to existing patients of the practice only.
Radiology requests are issued at the discretion of your doctor and must be clinically appropriate.
A referral may not be provided if you have not had a consultation within the last 6 months.
Your doctor may require you to book an appointment (telehealth or in-person) prior to issuing a referral.
Not all imaging qualifies for a Medicare rebate. Any out-of-pocket costs are the patient’s responsibility.
Results are not discussed via reception. A follow-up appointment may be required to review your results.
A $25 administration fee applies and is payable upon submission. If the request is declined, the fee will be refunded.
Please allow up to 5 business days for processing.
Patient Declaration:
I have read and agree to the above
Please sign:
*
Todays Date:
*
DD slash MM slash YYYY
office use only:
request approved
request declined
appointment required
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