Website - Radiology Request - (All Regions) Non ED Drs

Aged Care Imaging Request

For booking our mobile Ultrasound and X-ray service to your RACF. We strive to complete all scans within 1-3 business days.
Scan requested:
Region
Facility:
For facilities located in Brisbane's South (including East)
Facility:
For facilities located in Brisbane's North
Facility:
For facilities located in Brisbane's West
Price (hidden)
Facility Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Name:

First NameLast Name
Patient wing & room number
Behavioural condition:
⚠️ If history of non-compliance or risk of aggression, staff or family member presence is required to ensure completion of scan.
Contact:
Please enter a valid phone number.Format: 0000000000.
Add referral:
Upload referral:

Cancelof
⚠️ To avoid any delays in booking, please confirm the following details are visible on the referral:
eReferral - continued
Date of Birth:

DayMonthYear
Gender:
Medicare card and reference number:
Card expiry date (MM/YY):
Has the patient demonstrated uncooperative behaviour?
If yes, has the medical intervention been prescribed to assist in completing the scan?
Procedure
Examination Requested:
Clinical Details:
Known Allergies:
Infection Risk:
Referrer details
Referrer Name:

TitleFirst NameLast Name
Referrer Provider Number:
Referral Date:

DayMonthYear
Clinic Name:
Referrer Contact Number:
Please enter a valid phone number.Format: 0000000000.
Referrer Fax Number:
Please enter a valid phone number.Format: .
Referrer Email:
Regular GP name (if different to the above)
Name of person completing this form:
Please note that we do not provide ultrasound guided injections or Echocardiograms.
Please note that we cannot guarantee optimal imaging quality for Lumbar X-rays on patients with a BMI > 40.
Payment details

*Please note that payee details are required to reserve the booking.
Mobile services costs:
- X-ray: $130
- Ultrasound: $150
- X-ray + Ultrasound: $280
- DVA: No charge
- CAREPACT: No charge
*Please note, this fee is not claimable through Medicare.

*A $50 long distance fee applies for locations more than 50km from the Brisbane CBD.

*Weekend scans will be charged at 2 times the fee.
Who is responsible for the payment?
DVA card number:
Example format: QV1234567A
Primary contact name for payment:
Please provide their first and last name
Email address for Invoice:
Please provide the email address that the invoice will be sent to (if n/a, use your own).
Phone number:
An SMS will be sent to this number confirming the procedure. Format: 0000000000.
Has the mobile service been discussed with them:
Please ensure that the person responsible for paying the fee has been contacted and consented to the procedure.
Has the mobile service been discussed with them:
Please ensure that they are comfortable with proceeding and if necessary, ensure staff support is available.
Has the mobile service been discussed with CAREPACT:
CAREPACT is able to provide funding support for acute conditions that would normally require hospital transfer, or for immobile patients.
Additional comments:
Send a copy of this request to my email address:
Please fill in the email address you want a copy of the request to be sent to.
Should be Empty:

Aged Care Imaging Request

eReferral - continued

Procedure

Referrer details

Payment details