X-ray Referral Form

Please contact NCX for an appointment or more information on 03 313 2369 or via the contact page.

NCX has significantly reduced fees for ACC exams for all valid Community Service Card holders and children under 14 – see Fees page

Appointments or more information call 03 313 2369 or email via the contact page.

NCX has significantly reduced fees for ACC exams for all valid Community Service Card holders and children under 14 – see Fees page

Patient Details

First Name*

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Family Name*

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Date of Birth*

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Your Ethnicity*

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Ethnicity - Other*

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Address*

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Phone number*

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NHI number*

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X-Ray request*

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Clinical Indication and question*

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Side for imaging*

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Additional Clinical details*

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Smoker*

YesNo Invalid Input

Copy to

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ACC

YesNo Invalid Input

If not ACC a private charge will be payable

ACC Number*

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Injury (ACC code/s)*

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Date of Injury*

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Referrer*

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Email Address*

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Medical Registration number /HPI/ NZMC*

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EDI/Healthlink number

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Name of clinic*

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I confirm this referral is accurate and complete Invalid Input