e-Referrals

The easy, secure, and paperless way to send referrals directly to The Ultrasound Clinic.

For Medical Professionals Only

Important: This service is strictly for medical professionals only. If you need to book an appointment please use our booking form instead.

You are not logged in. If you log in or register, it makes creating new referrals easier as your information is added to the form automatically.

New Referral

Please complete all required fields

Fields marked with an asterisk (*) are required

Patient Information

Last Name *

First Name *

Date of Birth

NHI Number

Address

Email Address

Mobile Number *

Examination Details

Examination *

Clinical Information

Estimated Due Date

Last Menstrual Period

ACC Claim Number

Send Copies To

Referrer Information

Referrer Name *

Registration Number

Location

Signature *

Clear Signature

Preferences

Patient Contact Method

Receive Results Via *

Send me a copy of this referral

Need Help?

If you have any questions about the referral process or are experiencing technical difficulties, please contact us at (07) 929 41 51 or email [email protected].