Electronic Medical Imaging Request

Practitioner use only. This form will be delivered to the Medical Imaging Department and the patient where email provided.

Patient Details:

*Please complete so patient receives a copy of the request

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Private Bag 13, Leongatha  Vic  3953

Tel:  03 5667 5555

66 Koonwarra Road, Leongatha

Tel:  03 5667 5555

65 Bridge Street, Korumburra

Tel:  03 5654 2777

Patients, Clients & Families

Gippsland Southern Health Service acknowledges Aboriginal people as the traditional custodians of the land on which we operate. We commit to working respectfully to honour their ongoing cultural and spiritual connections to this country

© 2020 Gippsland Southern Health Service