Referral Form
polokwane@mitherapy.co.za |
+27 15 230 0128
Complete the form below to refer a patient
Referring Doctor *
Practice Number *
Patient Full Name *
Patient ID Number *
Date of Birth
Medical Aid Number
ICD-10 Code *
Reason for Referral *
Bone
Whole body
Regional
3 Phase
Thyroid
Scintigraphy
Uptake
Whole body
Lung
V/Q
Perfusion
Quantification
Kidney
DTPA
DMSA
MAG-3
Gaptopril
Gastric
Stomach Emptying
GIT Bleed
Meckel's
Milk Scan
Infection Imaging
Gallium
Labeled WBC Scan
Bone Marrow Scintigraphy
Therapy
Thyroid Ca
Hyperthyroidism
Osteoblastic Skeletal Meastases
Neuro-endocrine Tumors
Therapy (Continued)
Radiosynovectomy
Prostate Cancer
Hepatic Turnouts
Lymphomas
Heart
Myocardial Perfusion (MIBI)
MUGA
Hibernating Myocardium
Liver
Tincolloid
Haemangioma
Other (Continued)
Gallbladder (DISIDA)
Tektrotyd
Lymphoscintigraphy
Parathyroid
Other
Sentinel Lymph Node
Octreoscan
Brain
Other
Submit Referral
Thank you for your referral. It has been submitted successfully.
Referral Form Summary
Referring Doctor:
Practice Number:
Patient Name:
Patient ID:
Date of Birth:
Medical Aid Number:
ICD-10 Code:
Reason for Referral:
Selected Categories:
