Online Request or Referral

This form (below) is designed to be a digital/online referral for use by health professionals either referring a patient (instead of a paper referral) or requesting GMI contact them or their patient. If you have a paper referral use the UPLOAD REFERRAL option above

Type of Referral*
Choose the nature of your request or referral
Patient*
Firstname Surname
DOB
Date of birth

DD
MM
YYYY
Best Contact*
Please indicate the owner of the contact details below. This is the person we will contact to make the appointment.
Contact Phone*
Who we should call
Contact Email*
Details of Referral
Referring Practitioner*
Firstname Surname
Type of Scan*
Please select. To choose more than one, use the Ctrl (windows) or Cmd (mac). Tick on mobiles.
We would appreciate bringing any relevant results or data with you. If you had prior scans elsewhere then it would be helpful to know which practice.
We would appreciate letting us know the most recent PSA result. If a related MRI and/or biopsy has been done then we would like to know the result or where these were done.
For PRP therapy you will need to choose/specify a consultation below
Specific Doctor request
Select if a specific Dr is required for scan analysis and reporting or if a consultation is requested
For Digital Referrals
Provider Number*
Medicare provider number for this referral
Referral Date
Date of referral if different to today
Date Format: DD slash MM slash YYYY
Scan details
Specify any specific scan details needed, region to be scanned, etc
Clinical Notes*
Clinical background and aims of scan/study
Referrer Extras
Copies should only be sent to 3rd parties such that confidentiality is not breached. If more than one email is sent then both parties can view both email addresses.
- Copy of this referral emailed to address above (contact)
- Copy of this referral emailed to address below
Referrer Email
Email for a copy of this referral
Copies
List anyone you wish to receive a copy of the report
Digitally signed*
I acknowledge this is a genuine referral (for Medicare purposes).
If you need to upload a file
File
Upload your file(s) here. jpg, jpeg, png, pdf ONLY. Compatible mobile devices will direct you to capture or upload a photo or file of your referral.
Drop files here or

Accepted file types: jpg, jpeg, png, pdf.
Submitting your form
Consent*
I agree to the privacy policy.
By submitting this information you agree to our privacy policy. Your information will only be used for the purpose of making a booking and communicating with you and your patient/referrer. We will not release the information to a third party without your consent.
CAPTCHA

If you would like to submit another referral

If you need an A5 blank referral download it here

Details of Referral

For Digital Referrals

If you need to upload a file

Submitting your form