Telehealth X-Ray Online Referral Form

Step 1. Complete the referral form by clicking and typing in the boxes below and submitting this form online to X-Ray Newstead.
Step 2. We will telephone your patient, with your referral request in hand, to arrange an appointment. All COVID-19 safety precautions are taken into account for our safety and the patients.
Step 3. We will send you the Radiologist report and digital images by your preferred method of delivery.

To make this easy for you, if you have filled in our form before, just add your full name and we’ll fill in your personal details. By sending this document to us, you confirm all of the below information is true. By submitting the form, you are confirming the information below is accurate

Provider Name

First Name

Last Name

Provider Number

Name of Medical Practice

Address of Medical Practice

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Contact Information for Receiving the Report

Please let us know your preferred method of communication of the radiologist report and images, along with contact information.

Patient Name

First Name

Last Name

Patient Date of Birth

YYYY

Patient Phone Number

We prefer mobile numbers if possible

Diagnostic Imaging Service

Telehealth X-Ray Online Referral Form

X-Ray Newstead is proudly Launceston's only locally and family owned radiologist and x-ray clinic.