New Referrer Request

Request to add or amend a Referrer

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Existing Referrer

New Referrer

Referrer Type

GP

Midwife

Specialist

Physio

Other

Title

Dr

Mr

MW

Other

First Name

Surname

Medical Council Number or other practising number

Phone Number

Mobile Number

Fax Number

Email Address

Healthlink Address (EDI)

Name of Practice

Location Address

ACC ID / HPI Number

Specialty

Preferred Report Distribution(s)

Healthlink/EDI

Fax

Print

New Referral pads to be sent?

Yes

No

PACS Access

Yes

No

Required

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Select TRG Location

Select TRG LocationAucklandRotoruaTaupoNorthernHawkes Bay RadiologyNapier Radiology

If you require Inteleviewer PACS access – please click here to complete the form