Stationery

Epworth Medical Imaging customises referral request stationery in the following formats that adhere to the Medicare Benefits Schedule guidelines:

A4 printer paper

Customised A4 printer paper allows you to print laser requests directly from your practice management system.

A4 Radiology Request Form Download

For this option to work effectively, your practice management software must have its printer settings calibrated. For guidance to calibrate your printer, please contact Epworth Medical Imaging Support Team if your practice management system is listed: Best Practice, Genie, ZEDMED. Medical Director and Clinic to Cloud

A5 Theater Request Form

Download

A5 Dental Request Form

Download

A5 Breast Imaging Request Form

Download

A5 Inpatient Request Form

Download

A5 General Referral Form

Download

A4 Interventional Radiology & Pathology Request Form

Download

A4 Neurology PET/CT Request Form

Download

A4 PSMA PET/CT Request Form

Download

A4 General PET/CT Request form

Download

A4 Bone Densitometry Request Form

Download

CT Coronary Angiogram Request Form

Download

A4 Prostate MRI Request Form

Download

Handwritten Request Pads

Handwritten request pads have been developed for physicians that do not use a computer-based practice management system or prefer to handwrite requests. These request pads have fields for referrer details, required examination, clinical notes and delivery method. They can be used for any examination.

Personalised handwritten Request Pads

Handwritten request pads have been developed for physicians that do not use a computer-based practice management system or prefer to handwrite requests. Radiology Victoria can customise requests for any referrer. Personalised request pads include a pre-printed referrer name, address, phone, fax and provider number.

Request Referral Pads

To order new referral stationery, please click the link below to fill in our order form. If you are ordering personalised request pads, please ensure the correct details are entered to avoid delays including address, phone, fax, and provider number.

Order referral pads