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

    The World Health Organization (WHO) declared COVID-19 a worldwide pandemic on 11 March 2020. The Government of Western Australia has declared an end to the COVID-19 Pandemic State of Emergency on 4 Nov 2022. Please inquire with our medical receptionists about the relevant steps taken to manage bookings with COVID-19 still in the community.

    The following guidelines provided from St John of God Hospital apply within our clinics:

      • Face masks are not mandated but they should be worn in crowded indoor settings and where physical distancing is not possible; patients are free to wear them at their discretion.
      • We can confirm vaccination status of our employees and contractors meet WA Health regulations.
      • Hand hygiene is to be practiced at all times.
      • Please do not enter the clinic if you are unwell, tested positive for COVID-19 in the last seven days, been in close contact with a COVID-19 positive person in the last seven days, or if you have any symptoms of infectious illness such as: fever, cough, shortness of breath, sore throat, loss of smell or taste, runny nose, diarrhoea, nausea or vomiting.

    Please attempt to confirm your appointment before coming.

    Healthdirect Hotline: 1800 020 080 | Department of Health Health Warnings

    Updated 05 Jan 2023