IMAGING	REQUEST	BULK BILL 	
Dr A Gutmann 
Dr G Geier 
 
Date: <<Miscellaneous:Date (short)>>

PATIENT DETAILS:
Title: <<Patient Demographics:Title>>  Surname: <<Patient Demographics:Surname>>	 First Name: <<Patient Demographics:First Name>>     DOB: <<Patient Demographics:DOB>>     Age: <<Patient Demographics:Age>>			Medicare No.:  <<Patient Demographics:Medicare Number>>	DVA No.: <<Patient Demographics:DVA Number>>
Street: <<Patient Demographics:Full Address>>	Home Phone:	<<Patient Demographics:Phone (Home)>>   Mobile: <<Patient Demographics:Phone (Mobile)>>

SERVICE/S REQUIRED:
General X-ray	<<General X-ray>>	Pain Management	<<Pain Management>>	
CT	<<CT>>	Ultrasound	<<Ultrasound>>	
Dental Radiography	<<Dental Radiography>>	Musculoskeletal	<<Musculoskeletal>>	
Bone Densitometry	<<Bone Densitometry>>	Nuclear Medicine	<<Nuclear Medicine>>	
Mammography	<<Mammography>>	Vascular (Mon & Alt Fri)	<<Vascular>>	

REGION OF EXAM: 
<<Region of Exam:>>

CLINICAL NOTES:
<<Clinical Notes>>

REFERRING DOCTOR / ALLIED HEALTH PROFESSIONAL:
Name: <<Doctor:Name>>
Provider Number: <<Doctor:Provider Number>>
Practice Name: <<Practice:Name>>
Address:<<Practice:Address>>
Phone No: <<Practice:Phone>>
Fax No: <<Practice:Fax>>
Copy to: <<Copy To>>

Referrer’s Signature: 	__________________________________Date: <<Miscellaneous:Date (short)>>	ABN 25857 470 544

All patients will be bulk billed for all services, providing the clinical notes on the request form meet the criteria devised by Medicare. Patients referred by allied health professionals may incur a non rebate fee from Medicare if outside the referral guidelines of Medicare.  Please check with our receptionists.