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Referrer resource centre

Referral forms

Referrer InteleConnect login Referral forms Image access Support

Please download a Pacific Radiology referral form from the section below (unless you have an electronic request management system (ERMS) set up within your practice). If your imaging request is urgent please let us know so that we can ensure your patient receives a priority appointment booking.

Once you have filled in the referral form it can be given to your patient or emailed to the addresses below.

  • General Referral Form (Canterbury)
  • Pregnancy Referral Form (Canterbury)
  • PET/CT Referral Form (Canterbury)
  • National Indications for publicly funded PET/CT
  • Cardiac Imaging Referral Form (Canterbury)
  • Reference for Pregnancy scans - Section 88 Clinical Indications (PDF)


Email addresses for Canterbury Region:

[email protected]

Includes: CT, MRI, ICAT & CBCT

[email protected]

Includes: Dental, Bone Density (DEXA) Screening, US & x-ray

[email protected]

Includes: PET-CT
(Note: Nuclear Medicine direct to CDHB)

[email protected]

Includes: Timaru bookings - MRI

  • General Referral Form (Nelson)
  • MRI Referral Form (Nelson)
  • Reference for Pregnancy scans - Section 88 Clinical Indications (PDF)

Email addresses for Nelson:

[email protected]
Includes: Bone Density (DEXA), MRI, CT, US & x-ray

  • General Referral Form (Otago/Southland)
  • CT Referral Form (Otago/Southland)
  • Cardiac CT Request Form
  • MRI Referral Form (Otago/Southland)
  • Obstetric Ultrasound Referral Form (Otago/Southland)
  • Reference for Pregnancy scans - Section 88 Clinical Indications (PDF)

Email addresses for Otago/Southland:

[email protected]
Includes: Bone Density (DEXA), MRI, CT, US, x-ray & mammograms

[email protected]
Includes: Bone Density (DEXA), MRI, CT, US & x-ray & mammograms

[email protected]
Includes: MRI, CT, US, x-ray & mammograms

[email protected]
Includes: US & x-ray

  • General Referral Form (Wellington)
  • Pregnancy Ultrasound Referral Form (Wellington)
  • PETCT Referral Form (Wellington)
  • 18F-PSMA Prostate PET/CT Referral Form (Wellington)
  • General Referral Form (Palmerston North)
  • General Pregnancy Form (Palmerston North)
  • Musculoskeletal Referral Form (Palmerston North)
  • Reference for Pregnancy scans - Section 88 Clinical Indications (PDF)

Email addresses for Wellington/Manawatū:

[email protected]
Includes: Bone Density (DEXA), CT, Mamms, US & x-ray

[email protected]
Includes: Nuc Med, MRI & PET

  • General Referral Form (Waikato)
  • Cardiac Referral Form (Waikato)
  • Reference for Pregnancy scans - Section 88 Clinical Indications (PDF)

Email addresses for Waikato:

[email protected]
Includes: Bone Density (DEXA), CT, MRI, US, x-ray

If you would like to send referrals from within your Practice Management System (PMS) you will need to contact your PMS support team. Our IT team will work with your PMS support team if this is a viable solution.

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This content is AI generated and is not medical advice. Please check for accuracy.