Appointment Request

Please complete all fields in the below form to the best of your ability. A staff member from Specialist Imaging For Women will then respond as soon as we are able to confirm your appointment details.

First Name

Surname

Date of Birth

Street Address

Suburb

State

Postcode

Phone Number

Email

Referring Doctor

Type of Ultrasound

Due Date

Select options

Is this a twin/multiple pregnancy?

Please check your referral carefully. Is "Tubal Patency" or "Endo Bowel" written on your referral?

The tubal patency test requires additional patient information and preparation instructions and is unable to be booked online. Please phone 8609 4100 and our friendly staff will assist you to make an appointment.

Reason for ultrasound

Please type in as many details as to the type of ultrasound you are seeking here:

Please select

Preferred appointment time

Notes/Comments