For Doctors

Electronic referral for diagnostic imaging

Download referral form (PDF)

Print and fill out manually, or complete the digital form below.

Download PDF
Fill out the online form
Patient Information
Referring physician
Required examination
Clinical data and indication
Laboratory and risk data
ALLERGIES
IMPLANTS
PREGNANCY
Previous health events
Signature type
Electronic signature (for CBCT and RTG examinations) To sign the referral form for CT/RTG examinations, you will need the Autogram

For any questions, please contact us:

+421 2 2102 0702  ·  info@medirad.sk