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
For 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
For 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
Number Patient select
Patient Name and Surname
*
Date of Birth
*
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MM
1
2
3
4
5
6
7
8
9
10
11
12
YYYY
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
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/DEXA
Fluoroscopy
Interventional
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
If applicable, select the side to be examined*
*
N/A
Left
Right
Both
Xray Options – please select the preferred procedure
Paranasal Sinuses
Maximillio-Facial Bones
Chest
Chest & Ribs
Abdomen
Hip
Pelvis
Pelvis & Hip
Cervical Spine
Thoracic Spine
Lumbar Spine
Upper limb
Shoulder
Hand
Elbow
Wrist
Lower Limb
Hip
Knee
Ankle
Foot
Please add if any specific Xray Views are required:
Ultrasound Options
U/S Doppler
U/S Upper Limb Soft Tissue
U/S Shoulder
U/S Wrist
U/S Hand
U/S Thyroid
U/S soft tissue of the neck
U/S Breast
U/S Chest Wall
U/S Abdominal wall
U/S Upper abdomen
U/S Abdomen + pelvis
U/S Pelvis Transabdominal
U/S Pelvis Transvaginal
U/S Renal tract & bladder
U/S Testes
U/S Groin
U/S Hip
U/S Knee
U/S Lower limb soft tissue
U/S Ankle
U/S Foot
Please add if any specific Ultrasound 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:
Contrast study (if applicable)
Pre & Post
Post
None
Mammogram Options
Mammogram
Stereotactic Biopsy
VAB
Interventional Examination requested:
Next
Referring Doctor name and surname
*
Referrer Email
*
Phone number
Practice Number
*
Submit
WhatsApp us
