MRI Referrals - Go2imaging

Step 1 of 4

Please use this form if you would like our assistance with referring a patient for an MRI scan (or DEXA scan) to your local InHealth Centre. We will oversee the whole process, including arranging for the optimum type of scan (sequences and views), and a superior quality report from one of our preferred radiologists.
Step 1: Please complete the patient details and clinical detail forms to follow.
Step 2: To submit the form, please complete the payment using the online portal, either use your own credit / debit card (and arrange for the patient to reimburse you) or have the patient complete this step.
Steps 3 & 4: Your patient will be contacted by InHealth to arrange a time for their scan. You (the referrer) will receive the imaging report on email, usually within one to three days following the patient receiving their scan.

Patient Details

Title *

Address *

Name *

First

Last

Postcode *

Date of Birth *

Email *

Telephone *

Please use this form if you would like our assistance with referring a patient for an MRI scan (or DEXA scan) to your local InHealth Centre. We will oversee the whole process, including arranging for the optimum type of scan (sequences and views), and a superior quality report from one of our preferred radiologists.
Step 1: Please complete the patient details and clinical detail forms to follow. (completed)
Step 2: To submit the form, please complete the payment using the online portal, either use your own credit / debit card (and arrange for the patient to reimburse you) or have the patient complete this step. (completed)
Steps 3 & 4: Your patient will be contacted by InHealth to arrange a time for their scan. You (the referrer) will receive the imaging report on email, usually within one to three days following the patient receiving their scan.

Referring Clinician

Title

Name *

First

Last

Speciality / Profession *

Other Speciality / Profession

I confirm that i have patient's consent to provide their personal information with this referral

Professional registration number

Signature *

By typing your name above. this serves as your signature.

Hospital / Practice

Referral Date

Email Address *

Address *

Postcode

Telephone

Mobile Number *

Email

Patient Details

Relevant Clinical Details

Referring Clinician

Payment