Referral Form
Patient Referral Form

Please fill out the fields below and one of our team members will review the referral and respond accordingly. Fields marked with * are required

Privacy Notice: Western Ultrasound for Women is collecting personal information on this form to provide you and/or your patient with women’s medical diagnostic and imaging services. As part of our function and activities, we may use this information to contact you via phone, email, or by post. More information about our company’s privacy policy and information on how to contact us regarding our adherence to Australian Privacy Principles is available on our website at Privacy Policy page.

Patient’s Details


    Clinic Details


    Referral For



    Coronavirus (COVID-19) Health Alert

    Please reschedule your appointment, and DO NOT ENTER our facilities, if you:

    • Have returned from interstate or overseas travel in the last 14 days; OR
    • Have been in contact with someone who has returned from interstate or overseas travel; OR
    • Have been in contact with someone who has a confirmed case of Coronavirus COVID-19; OR
    • Have a fever, cough, runny nose, sore throat, difficulty breathing, fatigue, or any cold/flu like symptoms.

    If you fit this criteria, please self-isolate at home until the 15th day following travel or contact, even if you are feeling well. If you are showing respiratory or flu-like symptoms, telephone your doctor or hospital Emergency Department before presenting yourself. If you are experiencing severe symptoms, call '000' and advise the operator you are in self quarantine because of COVID-19 risk.

    Western Ultrasound is committed to the risk mitigation of Coronavirus COVID-19 as one of our priorities for patient safety and quality of care.

    Due to the COVID-19 pandemic there may be changes to regular operating hours. We apologise in advance for any inconvenience arising from measures we're taking for the safety of staff and patients.

    COVID-19 Health Information Hotline: 1800 020 080 | Department of Health Health Warnings