Make a Booking
Clinicians Portal
For Patients
Make a Booking
Get your images and Reports
Consent for Image sharing
Pay my Account
Branches
MRI Centralised Bookings
Find your nearest branch
All Branches
Our Services
X Ray
Ultrasound Imaging
CT Imaging
MRI
Women’s Imaging
GIT imaging
PET CT
Interventional Radiology
Personalised Screening Service
Chest X-rays for Visa applications
Our Clinicians
Order Printed Request Pads
Access Imaging Tools (PACS)
Submit an Online Referral
Contact Us
Careers
Browse Vacancies
Bursary Programme
About Us
Management Team
Contact Us
Frequently Asked Questions
Make a Booking
Clinicians Portal
For Patients
Make a Booking
Get your images and Reports
Consent for Image sharing
Pay my Account
Branches
MRI Centralised Bookings
Find your nearest branch
All Branches
Our Services
X Ray
Ultrasound Imaging
CT Imaging
MRI
Women’s Imaging
GIT imaging
PET CT
Interventional Radiology
Personalised Screening Service
Chest X-rays for Visa applications
Our Clinicians
Order Printed Request Pads
Access Imaging Tools (PACS)
Submit an Online Referral
Contact Us
Careers
Browse Vacancies
Bursary Programme
About Us
Management Team
Contact Us
Frequently Asked Questions
Make a Booking
Clinicians Portal
Home
Digital Radiology request form
Digital Radiology Request Form
Complete the below fields with the relevant information.
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 4
Patient Name and Surname
*
Date of Birth
*
Patient Email Address
Patient Phone Number
Medical Aid
Medical Aid number
Next
Is this a WCA case?
Yes
Company Name
Date of Injury
Next
Preferred Branch
*
Please select your preferred branch
Morton & Partners Riverlands Outpatient
Life Vincent Pallotti
Mediclinic Cape Town
Mediclinic Milnerton
Melomed Mitchells Plain
Melomed Bellville
Melomed Gatesville
Melomed Richards Bay
Melomed Tokai
Netcare Christiaan Barnard
Rondebosch Medical Centre
Centralized MRI
Intercare Century City
Kingsbury Radiology
Centric Radiology
Medicross Kenilworth (XRAY ONLY)
Medicross Langeberg (XRAY ONLY)
Medicross Parow (XRAY ONLY)
Medicross Tableview (XRAY ONLY)
Medicross Tokai (XRAY ONLY)
Please select the below, if applicable:
Urgent case
Portable
If urgent, please indicate:
Inpatient
Outpatient
Ward name
Clinical indication
*
ICD 10 code
*
Examination requested:
*
XRay
CT
MRI
Mammogram
Ultrasound
BMD
To select multiple modalities, please indicate in your clinical indications any specified views required.
Please select if applicable (MRI/CT only)
Pacemaker
Sleep Apnea
Diabetic
Implants
Hypertension
Allergies
Claustrophobia
Dialysis
Preferred indication Company
If applicable, select the side to be examined*
*
N/A
Left
Right
Both
Xray Options – please select the preferred procedure
Paranasal Sinuses
Shoulder
Pelvis & Hip
Maximillio-Facial Bones
Elbow
Hip
Cervical Spine
Upper limb
Lower Limb
Thoracic Spine
Wrist
Knee
Lumbar Spine
Hand
Ankle
Chest
Abdomen
Foot
Chest & Ribs
Pelvis
Please add if any specific Xray Views are required:
Ultrasound Options
U/S Doppler
U/S Hand
U/S Renal tract & bladder
U/S soft tissue of the neck
U/S Upper Limb Soft Tissue
U/S Testes
U/S Thyroid
U/S Upper abdomen
U/S Groin
U/S Breast
U/S Abdomen + pelvis
U/S Lower limb soft tissue
U/S Chest Wall
U/S Abdominal wall
U/S Knee
U/S Shoulder
U/S Pelvis Transabdominal
U/S Ankle
U/S Wrist
U/S Pelvis Transvaginal
U/S Foot
Please add if any specific Xray Views are required:
CT Options
CT Stroke
CT Lumbar Spine
CT Renal Tract for a stone
CT Brain
CT Chest
CT Colonoscopy
CTA Head/Neck
CTPA
CT Bony Pelvis
CT BOS to symph pubis
CTA Heart Vessels
CTA Pheripheral Outflow
CT Sinuses
CT Calcium Score (Cardiac)
CT Knee
CT Facial Bones
CT TAVI assessment
CT Ankle
CT Temporal Bones
CTA Thoracic Aorta & Branches
CT Planning
CTA Carotid
CTA Abdo Aorta & Branches
CT Drainage
CT Soft tissue of the neck
CTA
CT Abscess + Cyst Drainage
CT Cervical Spine
CT Chest, Abdo & Pelvis
CT FNA Biopsy
CT Thoracic Spine
CT Abdo & Pelvis
Please add if any specific CT Views are required:
MR Options
MR Brain
MR Lumber Spine
MR Bony Pelvis (Hips)
MRA Brain
MR Sacro-Iliac Joints
MR Soft Tissue Pelvis
MR Orbits
MR Whole Body Screening
MR Shoulder
MR TM Joints
MRA Cardiac
MR Upper Arm
IAMS
MR Breast
MR Elbow
MR Pituitary Fossia
MR Enterography
MR Forearm
MR Cervical Spine
MR Liver/Pancreas
MR Hand & Wrist
MR Brachial Plexus
MRCP
MR Femur
MRA Carotids
MR Abdomen with MRCP
MR Knee
MRA Brain & Carotids
MR Kidneys
MR Ankle
MR Thoracic Spine
MR Prostate
MR Foot
Please add if any specific MR Views are required or contrast required:
Mammogram Options
Mammogram
Stereotactic Biopsy
VAB
Next
Referring Doctor name and surname
*
Referrer Email
*
Phone number
Practice Number
*
Submit
WhatsApp us
