> Health assessments for insurance
> Full range of pathology services
> Medical and paramedical testing
> Expert practitioners

Referral Form

* indicates mandatory field

Referring Advisor

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Insurance Company

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Service Required - mark box

Specialist Insurance Assessment
GP Insurance Assessment (GP)
GP Insurance Assessment (Own Doctor)
Paramedical Insurance Assessment
AIA - Short Form Medical
AMP - Express Health Check
Asteron - Quickcheck
Aviva - Rapid Check
AXA - Mini Check
Comminsure - Medilite
Clearview - Mini Check
BT - Quickcheck
One Path - Medi Quick
MLC - Rapid check
Suncorp - Quickcheck
Tal - Fast Check
Westpac - Quickcheck
Zurich - Express Exam
Three Blood Pressure readings at 5 minute intervals
Teleunderwriting
Client personal medical history report (P.M.A.R)
Electrocardiogram (resting ECG)
Exercise stress test (exercise ECG)
Stress Echocardiogram
Chest X-Ray
Echocardiogram
Lung Function Test
24hr Blood Pressure Monitor
24hr Electrocardiogram Monitor
Breast Exam
Results of current mammogram (within last 12 months)
PPS Mutual Quick Check
Zurich Futurewise - Quick Check
Zurich Futurewise - Short Medical Report
Metlife Paramedical
Metlife Quick check
Metlife Medical Examination
Questionnaire (Please specify:)

Client

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// (dd/mm/yyyy)
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Male Female
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Place for Tests



Preferred times for service (in order of preference):

Preference Day Time
1
2
3
4

Blood Tests

NON-Fasting MBA20 (inc HbA1c,HDL/LDL/Chol)
NON-Fasting MBA20 (inc HDL/LDL/Chol)
Fasting MBA20 (inc HDL/LDL/Chol)
Hep B (antigens) Hep C (antibodies)
H.I.V
Full blood exam/Full blood count (FBE/FBC)
ESR
PSA
Serum Iron Studies
Thyroid Function
HbA1c - (Glycosylated haemoglobin)
Urine Micro & Culture (MSU)
Urine Micro & Culture (MSU) with red cell morphology
Urine drug screen and report
Cotinine
Fasting Blood Glucose Test
Lipids Profile
Glucose Tolerance
Liver Function Test
Hepatitis C PCR
24 Hour Urinary Protein
CDT - Carbohydrate Deficient Transferrin
Creatinine Clearance Blood test
Creatinine Clearance Urine test
C Reactive Protein
PSA Free (including Free to Total Ratio)
Hepatitis B e Antigen
Testosterone Blood test
Albumin / Creatinine Ratio urine test
Limousine Service to Appointment (Only with insurance company approval)
Copy of results to client