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About You
Let us know how to get back to you
First Name
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Last Name
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Email Address
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Phone Number
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Date of Birth
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Date Format: DD slash MM slash YYYY
Postcode
*
How did you hear about us?
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My specialist
My GP
Friends / Friends of Family
Google
Social Media
Other
About Your Appointment
Please note: This does not constitute a booking. We need to check our specialists' calendar and confirm that an appointment is available for you. Please await our reply before scheduling your visit
Preferred Date
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Date Format: DD slash MM slash YYYY
Morning or afternoon?
*
Morning
Afternoon
Previous Client?
*
No
Yes
Additional booking request notes
Your Examination
Please give us some details about your upcoming examination. Our Nedlands location caters to all forms of imaging.
What type of examination are you booking?
MRI
CT
Ultrasound
Biopsy
Other
Please provide details of what body regions are to be examined
Referral
Upload a scanned copy of your referral form from your doctor/practitioner. All referral forms are accepted at ChestRad, even referral forms from other providers.
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Accepted file types: jpg, png, pdf.
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