Online referral Submit an online referral if you are a clinician. "*" indicates required fields Step 1 of 3 - Doctor and Patient information 33% Clinicians can submit online patient referrals by completing this form. • Please note that these submissions will only be monitored during business hours. • If you submit an urgent case, please phone the branch to confirm receipt and immediate attention. Doctor InformationPreferred branch for examination*Preferred branch for examination *SCP Radiology BrackenfellSCP Radiology Cape GateSCP Radiology CeresSCP Radiology DurbanvilleSCP Radiology Durbanville OrthopaedicSCP Radiology Louis Leipoldt and MRSCP Radiology MalmesburySCP Radiology PaarlSCP Radiology Paarl MedicentreSCP Radiology PanoramaSCP Radiology Panorama Healthcare CentreSCP Radiology Panorama MR CentreSCP Radiology RobertsonSCP Radiology SwellendamSCP Radiology Tygervalley Mammography CentreSCP Radiology VredenburgSCP Radiology VredendalSCP Radiology WillowbridgeSCP Radiology WorcesterReferrer name and surname* Name Surname BHF Practice number*Referrer Email address* Referrer Contact NumberPatient InformationPatient Name and Surname* Name Surname Patient Date of Birth*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient Email Patient Contact NumberMedical Aid NameMedical Aid NameAECI Medical Aid SocietyAlliance-Midmed Medical SchemeAnglo Medical SchemeAnglovaal Group Medical SchemeBankmedBarloworld Medical SchemeBestmed Medical SchemeBMW Employees Medical Aid SocietyBonitas Medical FundBP Medical Aid SocietyBuilding & Construction Industry Medical Aid FundCape Medical PlanChartered Accountants (SA) Medical Aid Fund (CAMAF)Compcare Wellness Medical SchemeDe Beers Benefit SocietyDiscovery Health Medical SchemeEngen Medical Benefit FundFedhealth Medical SchemeFishing Industry Medical Scheme (Fishmed)Food Workers Medical Benefit FundGenesis Medical SchemeGlencore Medical SchemeGolden Arrow Employees' Medical Benefit FundGovernment Employees Medical Scheme (GEMS)Horizon Medical SchemeImpala Medical PlanImperial Group Medical SchemeKeyhealthLA-Health Medical SchemeLibcare Medical SchemeLonmin Medical SchemeMakoti Medical SchemeMalcor Medical SchemeMassmart Health PlanMBMed Medical Aid FundMedihelpMedimed Medical SchemeMedipos Medical SchemeMedshield Medical SchemeMomentum HealthMotohealth CareNaspers Medical FundNetcare Medical SchemeOld Mutual Staff Medical Aid FundParmed Medical Aid SchemePG Group Medical SchemePick n Pay Medical SchemePlatinum HealthProfmedRand Water Medical SchemeRemedi Medical Aid SchemeRetail Medical SchemeRhodes University Medical SchemeSABC Medical Aid SchemeSAMWUMedSasolmedSedmedSisonke Health Medical SchemeSizwe Hosmed Medical SchemeSouth African Breweries Medical Aid Scheme (SABMAS)South African Police Service Medical Scheme (POLMED)Suremed HealthTFG Medical Aid SchemeThebemedTiger Brands Medical SchemeTransmed Medical FundTsogo Sun Group Medical SchemeUmvuzo Health Medical SchemeUniversity of Kwa-Zulu Natal Medical SchemeWitbank Coalfields Medical Aid SchemeWooltru Healthcare FundPrivateOtherMedical aid numberOther Medical AidContact Patient of appointment Select if SCP should contact the patient for an appointment. (Please ensure that you have provided the patient’s phone number) WCA InformationPlease select if this is a WCA case Please select if this is a WCA case Patient’s place of employment (company/organisation name)Date of injuryDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please include all WCA-related documentation, e.g. Employer’s Report of Accident (WCL2), First Medical Report (WCL4), Progress Medical Report (WCL5), Annexure A & B, etc. Drop files here or Select files Max. file size: 100 MB. Routine/Urgent/Mobile Routine Urgent examination Mobile examination in ward/ICU If urgent, please indicate Outpatient Ward Ward NumberPatient’s clinical history*ICD10 code(s)Examination requested*Please select to view specific examinations. X-ray CT MRI Mammogram Ultrasound Interventional BMD Fluoroscopy X-Ray Options Chest Chest & Ribs Ankle Foot Knee Wrist Hand Abdomen Lumbar Spine Cervical Spine Thoracic Spine Shoulder Hip Pelvis Pelvis & Hip Elbow Upper limb Lower Limb Maximillio-Facial Bones Paranasal Sinuses Select side to be examined N/A Left Right Both Mammogram Options Mammogram Biopsy - Breast VABB - Breast FNA - Breast FNA - Axilla Localisation - Breast Marker Placement - Breast Guidance Method Stereotactic Ultrasound guided Maximillio-Facial Bones Specific Cephalogram Orthopantomogram Mandible Facial Bones Nasal Bones Chest Specific PA & Lateral Single View SAF Chest Portable Immigration Diving Upper limb Specific Forearm Humerus Wrist Specific Standard Scaphoid Hand Specific Standard Fingers Abdomen Specific Single Supine & Erect Lumbar Spine Standard Stress Cervical Spine Standard Stress Shoulder Standard Impingement view Pelvis Specific Standard With Judet views Weight-bearing Pelvis & Hip Specific PA & Oblique views With Judet views Weight-bearing Lower Limb Specific Femur Tib-Fib Knee Specific AP & Lateral Patella Multiple including oblique views Multiple Views Stress Weight-bearing Ankle Specific Standard Stress Weight-bearing Foot Specific Standard Weight-bearing CT options CT Stroke CT Brain CTA Carotid Head/Neck CT BOS to symph pubis CT Sinuses CT Facial Bones CT Temporal Bones CT Soft tissue of the neck CT Cervical Spine CT Thoracic Spine CT Lumbar Spine CT Chest CTPA CTA Heart Vessels CT Calcium Score (Cardiac) CT TAVI assessment CTA Thoracic Aorta & Branches CTA Abdo Aorta & Branches CT Chest, Abdo & Pelvis CT Abdo & Pelvis CT Renal Tract for a stone CT Colonoscopy CT Bony Pelvis CTA Pheripheral Outflow CT Knee CT Ankle CT Oncology Planning CT Guided Drainage CT Abscess + Cyst Drainage CT Guided Biopsy CT Stroke CTA Extracranial Neck CTA Intracranial Brain CTA Carotid Head/Neck Head & Neck Head COW Neck only CT Brain Including CTA Extracranial Neck CTA Intracranial Brain CT Sinuses Specific Limited Full study On Cone Beam CT CT Chest Specific Arterial High-res Non-contrasted CT Facial Bones Specific On Cone Beam CT CT Temporal Bones Specific On Cone Beam CT CTA Pheripheral Outflow Upper limbs Lower limbs Ultrasound Options U/S Abdomen + pelvis U/S Upper abdomen U/S Lower limb soft tissue U/S Renal tract & bladder U/S Pelvis Transabdominal U/S Thyroid U/S Abdominal wall U/S Shoulder U/S Carotid Doppler U/S soft tissue of the neck U/S Testes U/S Upper Limb Soft Tissue U/S Breast U/S Chest Wall U/S Ankle U/S Knee U/S Foot U/S Pelvis Transvaginal U/S Hip U/S Elbow U/S Wrist U/S Groin U/S Hand U/S Arterial Doppler U/S Venous Doppler U/S Arterial Doppler Upper limbs Lower limbs U/S Venous Doppler Upper limbs Lower limbs MRI options MR Brain MRA Brain MR Orbits MR TM Joints IAMS MR Pituitary Fossia MR Cervical Spine MR Brachial Plexus MRA Carotids MRA Brain & Carotids MR Thoracic Spine MR Lumbar Spine MR Whole Spine MR Sacro-Iliac Joints MR Whole Body Screening MRA Cardiac MR Breast MR Enterography MR Liver/Pancreas MRCP MR Abdomen with MRCP MR Kidneys MR Prostate MR Female Pelvis MR Bony Pelvis (Hips) MR Soft Tissue Pelvis MR Shoulder MR Upper Arm MR Elbow MR Forearm MR Hand & Wrist MR Femur MR Knee MR Ankle MR Foot CT Contrast No Contrast Contrast Pre- & Post contrast Unknown MRI Contrast No Contrast Contrast Pre- & Post contrast Unknown Interventional SpecificBMD Options Including Body Composition Fluoroscopy Specific Please indicate if we should send a copy of this referral note to: Your email address Your patient’s email address (if provided) Disclaimer* Disclaimer: By clicking “Submit”, I hereby acknowledge that this referral is electronically signed by me, the referring clinician, and I am formally requesting this examination.* This field is hidden when viewing the formTimestamp
