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Referring Doctors



Title
 
Name
Firstname
Initials
Surname
Profession GP   Midwife   Physiotherapist   Other:
New Zealand Medical
Council Number		  
Email
Phone
Mobile
Default Film Delivery Patient   Referring Practice   As indicated on form
Default Report Delivery Post   Email   Healthlink   Fax   As indicated on form

Practice 1
Address
Phone
Fax
Healthlink Mailbox
Email

Practice 2
Address
Phone
Fax
Healthlink Mailbox
Email
JPACS server

Do you wish to view patients images via our JPACS Image Server?

If you indicate that you wish to view patients images you will be requested to attend a presentation evening at Ascot Radiology on how to make full use of this technology

No     As Requested

Ascot Radiology Limited, Auckland, New Zealand


ASCOT INTEGRATED HOSPITAL

90 Green Lane Road East, Remuera

ASCOT CENTRAL

7 Ellerslie Racecourse Drive, Remuera
PO Box 28 268, Remuera, Auckland 1541, New Zealand

TEL:

+64 9 520 9550  

FAX:

+64 9 520 9551  

EMAIL:



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