Roselea Imaging Services
Booking Request
Upload referral
Please take a clear photo or scan the referral document(s)
Please upload referral file.
Procedure
No booking required for X-Ray. Please walk in during opening hours.
Preferred Date
Please enter date DD/MM/YYYY.
Clinic is closed on Weekends & Public holidays
Preferred Time
Any Day - Flexible
First Available
Morning
Afternoon
Please your preferred time.
Patient info
Title
Mr
Mrs
Ms
Miss
Dr
Prof
Please your title.
First name
Please provide a first name.
Last name
Please provide a family name.
Other names
Preferred name
Date of Birth
Please enter date DD/MM/YYYY.
Gender
Male
Female
Please your gender.
Contact details
Mobile
Please provide a valid mobile number.
Home Phone
Please provide a valid phone number.
Email
Please provide a valid email.
Address
No.
Please provide a valid Street Number.
Stree Name
Please provide a Stree.
Suburb
Please provide a valid Suburb.
Postcode
Please provide a valid postcode.
State
NSW
QLD
SA
TAS
VIC
NT
WA
Country
Please provide a valid country.
Is the patient under 18 years old
Guardian details
(if patient is under 18 yrs. of age)
First name
Last name
Date of Birth
Please provide date as DD/MM/YYYY
Mobile
Home phone
Email
Invalid email
Relationship to patient
Address
No.
Please provide a valid Street Number.
Stree Name
Please provide a Stree.
Suburb
Please provide a valid Suburb.
Postcode
Please provide a valid postcode.
State
NSW
QLD
SA
TAS
VIC
NT
WA
Country
Please provide a valid country.
Do you have a current Medicare Card
Medicare number
Please enter a valid medicare number
Reference
Please enter a valid reference number. This is the number next to your name
Expiry (month)
Month should be a value from 01 to 12
Expiry (year)
Please enter a valid year. This cannot be in past
Do you have a current Pension Card
Pensioner card number
Expiry
Do you have a current Government Health Care Card
Government health care
Expiry
Do you have a current DVA card
Dept. of Veteran Affairs
Card type
Gold
White
Other
Expiry
Are you claiming Workers
Workers compensation details
Insurance company
Claim number
Are you claiming Motor vehicle accident
WA motor vehicle accident incident details
Injury Date
Please enter date of injury DD/MM/YYYY.
Claim number
Employer name
Employer address
No.
Please provide a valid Street Number.
Stree Name
Please provide a Stree.
Suburb
Please provide a valid Suburb.
Postcode
Please provide a valid postcode.
State
NSW
QLD
SA
TAS
VIC
NT
WA
Country
Please provide a valid country.
Preferred Method of Contact
Call
Email
Please your preferred contact method.
Comments
How can we improve our online bookings
Please attach referral
Send Request
This is only a request. One of our staff members will contact you to confirm your appointment