UPLOAD YOUR REFERRAL(S) - Garran Medical Imaging

UPLOAD YOUR REFERRAL(S)

Name*
of the person undergoing the scan
First Last
DOB*
Date of birth
Date Format: DD slash MM slash YYYY
Contact phone*
Who we should call to arrange the booking
Email
Contact email
Enter Email Confirm Email
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.
Drop files here or

Accepted file types: jpg, jpeg, png, pdf.
Optional information
Any important information we should know before contacting you?
Consent*
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 in regard to the booking and scan result. Unless you consent otherwise, this information is shared between our staff and your referrer only.
I agree to the privacy policy.
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