Referral

referral

city clinic:
- allied health services
dexa scan sydney:
- bca, bmd & visceral fat scans
assist group:
- compulsory medicals
- drug testing
- flu-vax
- pathology
- pre-employment medicals
- compulsory medicals

Date

DayMonthYear

City Clinic: Level 7, 50 King St Sydney
Just up from the Apple Store toward Darling Harbour

Referred by

Provider No.

Practice or Centre Name and Suburb

Clinical Notes

Referred for

The Following Medicare item numbers are entitled to a rebate

Reason for referral

For your patient to receive a Medicare rebate for BMD at least one of the following Medicare items need to be ticked

Note:

Medicare Eligible

Item Number:

Authorised by

Special Considerations

Patient Name

TitleFirst NameLast Name

Confirm with patient via?

Their Mobile?

Please enter patient's mobile number

Their E-mail

Please enter patient's e-mail address

Your E-mail

For a copy of referral and file notes

Your Phone Number

E-mail a copy of referral?

Recipient E-mail

Antispam