Change an Appointment

Patients and carers can request an appointment at any one of our Queensland X-Ray practices. Simply complete the form below, and one of our booking staff will contact you on the working day to confirm the availability of the appointment requested.

Application Form

Form Legend

*: indicates a required field
!: indicates a field that requires attention

Do you have a request form from a medical practitioner?

(Please Note: If you require an OPG or a plain x-ray examination an appointment is not required.)

PATIENT DETAILS

Patient Title

*Required Field First Name

*Required Field Last Name

*Required Field Date of Birth

*Required Field Gender

Male
Female

Address

Suburb/Town

State

Postcode

Preferred method of contact:

*Required Field Contact Phone

*Required Field Email Address

If you are not the patient please provide your details below:

First Name

Last Name

Contact Phone Number

Referring Doctor's Name

Referring Clinic Name

*Required Field Procedure/Examination Required

Clinical Indications

See request form (i.e. notes written by your doctor)

*Required Field Preferred Area

*Required Field Practice in Area selected

Procedures Performed at this Practice

(Please check the field below to ensure the procedure you require is available at this location)

*Required Field Current Appointment Time

Current Date/Time Preference

*Required Field Choose New Appointment Times

(Please note: there may be delays of up to two weeks for certain procedures, in particular for ultrasound appointments)

Preference 1

Preference 2

Preference 3

Patient Preparation

Further Information that you feel would be useful for us to know