Referral Forms

Please fax to (01) 6579099 or email to medical@chartermedical.ie and the referrals will be processed and you/your patient contacted to make an appointment and complete a questionnaire. The questionnaire allows us to tailor our examination to meet patient’s need’s. This avoids wasting time for patients and allows us to prepare sufficiently.

Forms

• DIAGNOSTIC REFERRAL FORM (- to request any of the diagnostic services which we provide.)
• FEMALE DEXA QUESTIONNAIRE (- this enables us to provide thorough and appropriate advice including treatment if appropriate.)
• MALE DEXA QUESTIONNAIRE (- this enables us to provide thorough and appropriate advice including treatment if appropriate.)
• CT CONTRAST QUESTIONNAIRE (- this screening questionnaire enables Charter to treat patients appropriately, not exposing anyone to adverse unnecessary risks.)
• CHARTER MRI SAFETY QUESTIONNAIRE (– this screening questionnaire is crucial to maintain MRI safety.)