X-ray Referral		
PATIENT DETAILS		
Name	<PtName>	
Address	<PtAddress>	
DOB	<PtDoB>	
Phone	<PtPhoneH>
<PtPhoneMob>
<PtPhoneWk>	
Medicare No	<PtMCNo><PtMCExpiry>	
Gender	<PtSex>	
Lungscreen ID	<Lungscreen ID>	
E<LungScreen ID>mail	<PtEmail>	
Current Coal Mine Employer	<Current Coal Mine Employer>	
EXAMINATION		
International Labour Organization ( ILO ) Chest X-ray	<International Labour Organization ( ILO ) Chest X-ra>	
REASON FOR X-RAY REQUEST	<REASON FOR X-RAY REQUEST>	
Clinical Notes:	<Reason for X-Ray Request- Clinical Notes:>	
REFERRING DR		
Name	<DrName>	
Practice Location:	<Practice>
<UsrAddress>	
Provider Number	<DrProviderNo>	
Email	<DrEmail>	
Phone	<DrPhone>	
Fax	<DrFax>	
Signature	

	
Date	<FormattedDate>	
URGENT	<Urgent?>	

PATIENT CONSENT
I understand the X-ray clinic I visit to obtain my chest X-ray image will provide the image to Lungscreen Australia for the purpose of reading my X-ray to the International Labour Organization Classification of Radiographs of Pneumoconioses (ILO Classification).

PATIENT INFORMATION

1.	Register your details at our website www.lungscreen.com and record your Lungscreen ID at the top of this form in the “patient details” section.
2.	Visit a registered X-ray clinic to have your chest X-ray. To find a list of registered clinics refer to the back of this referral.
3.	The X-ray clinic will send your chest X-ray image to Lungscreen for assessment and completion of your ILO B-reader report.
4.	You will receive a notification at your registered email address when your result (ILO B-reader report) is available for viewing on the Lungscreen portal.
5.	Your result will also be sent to your referring doctor.

info@lungscreen.com
lungscreen.com
Fax   07  3220 6838 
ABN 25 615 712 420

I give consent to the X-ray clinic to send my chest X-ray image to Lungscreen Australia for the purpose of providing an ILO Classification. Signature: 		Date:   	

Registered X-ray Clinics

Region	Registered Practice	Address	Phone	
Biloela	Central Queensland Radiology
Biloela Hospital	2 Hospital Rd
Biloela QLD 4715	(07) 4492 7046	

Brisbane	Moreton Bay Radiology
Morayfield	
Shop 09 Morayfield Village 177-189 Morayfield Rd
Morayfield QLD 4506	

(07) 5428 4800	

Queensland X-ray
Coorparoo	
342 Old Cleveland Rd Coorparoo QLD 4151	
1300 781 926	

Queensland X-ray
Browns Plains	
14 Grand Plaza Dr Browns Plains QLD 4118	
1300 781 926	

I-MED
Ascot	
134 Racecourse Rd
Ascot QLD 4077	
(07) 3262 8588	

I-MED
North Lakes	
101/6 North Lakes Dr North Lakes QLD 4509	
(07) 3028 1050	

Emerald	Central Queensland Radiology
Emerald Hospital	
69 Hospital Road
Emerald QLD 4720	
(07) 4987 9442	

I-MED
Emerald	
112 Egerton St
Emerald QLD 4720	
(07) 4987 4500	

Gladstone	Central Queensland Radiology
Gladstone	
206 - 214 Philip St
Gladstone QLD 4680	
(07) 4978 9600	

Central Queensland Radiology
Gladstone Hospital	
Park St
Gladstone QLD 4680	
(07) 4976 3363	

I-MED
Gladstone Mater Hospital	
50 Rossella St
Gladstone QLD 4680	
(07) 4972 6544	

Gold Coast	Queensland X-ray
Southport	128 Queen St
Southport QLD 4215	1300 781 926	
Mackay	Queensland X-ray
Fourways	96 Nebo Rd
West Mackay QLD 4740	1300 781 926	

Rockhampton	Central Queensland Radiology
Rockhampton	
QTV House, 5 Aquatic Place North Rockhampton QLD 4701	
(07) 4926 9888	

Central Queensland Radiology
Rockhampton Hospital	
Canning St Rockhampton QLD 4700	
(07) 4920 6284	

Central Queensland Radiology
Hillcrest Hospital	
4 Talford st
The Range QLD 4700	
(07) 4921 4600	

I-MED
Stockland Rockhampton Shopping Centre	
331 Yaamba Rd
North Rockhampton QLD 4701	
(07) 4931 0400	

Sunshine Coast	Sunshine Coast Radiology
Buderim	
12-14 King St
Buderim QLD 4556	
1300 697 226	

Sunshine Coast Radiology
Maroochydore	
60 Wises Rd
Maroochydore QLD 4558	
1300 697 226	

Sunshine Coast Radiology
Nambour	
42 Howard St
Nambour QLD 4560	
1300 697 226	

Sunshine Coast Radiology
Sunshine Coast University Private Hospital	
3 Doherty St
Birtinya QLD 4575	
1300 697 226	

Sunshine Coast Radiology
Selangor Private Hospital	
62 Netherton St
Nambour QLD 4560	
1300 697 226	

Sunshine Coast Radiology
Sippy Downs	
2/1 Chancellor Boulevard Sippy Downs QLD 4556	
1300 697 226	

Sunshine Coast Radiology
Warana	
1 Main Dr
Warana QLD 4575	
1300 697 226	

Yeppoon	Central Queensland Radiology
Capricorn Coast Hospital	
8 Hoskyn Dr
Yeppoon QLD 4703	
(07) 4913 3150	

I-MED
Yeppoon	
55 Cliff St
Yeppoon QLD 4703	
(07) 4939 1096