CT Scan Referral

Please note we need approximately 24hrs to obtain authorisation for a non emergency CT scan. Once authorisation is obtained we will contact you and your patient with a date and time of CT Scan.

CT Scan Request Form

* Indicates required field

Doctor's Name *

First

Last

Doctor's Phone Number *

Doctors Email *

Doctor's Practice Number *

Copy doctor's email *

Patient Name *

First

Last

ID Number *

Patient Phone Number *

Gender *

Male Female

Medical Aid *

Medical Aid Number *

Dependent Code *

Allergies *

None known Iodine other (Please specify

Allergy Details *

Diagnosis *

ICD10 Code *

Weight *

Height *

CT Scan 1 - Please indicate with or without contrast *

CT Scan 2 - Please indicate with or without contrast *

Creatinine (Contrasted Scans Only) *

eGFR (Contrasted Scans Only) *

Clinical Details *

Submit

Refer a Patient for a CT Scan

CT Scan Request Form

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