Imaging Request · 30 Cuthberts Road, Alfredton VIC 3350 · 03 5339 4493
Kaw Chiropractic
30 Cuthberts Road, Alfredton VIC 3350 · Tel: 03 5339 4493
Select regions and views
Upper
Lower
Chest
All 5 should be Yes to proceed
Is the potential benefit of the X-ray outweighed by the potential harm?
Is there appropriate evidence to support taking an X-ray in this case?
Is a decision to take an X-ray in this case supported by my clinical experience?
Will an X-ray significantly impact my management of this case?
Does the patient still consent to the investigation?
Select the reason for each region — defaults to Biomechanical Dysfunction
Select examination regions to see clinical indications
Or use a Quick Preset above
Symptoms, duration, relevant history
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Sign here
Dr. Stephen Weightman #6205134Y
Kaw Chiropractic
Signature Date: 16/04/2026
Send referral to Kaw Chiropractic
Sends the completed form directly — no email client needed
Patient: _______________
DOB: ___/___/______ Sex: ___
Address: _______________
Tel: _______________
Medicare #: __________/_
Examination Requested:
Clinical Indications:
Clinical Details:
_______________
Clinical Justification:
1. Is the potential benefit of the X-ray outweighed by the potential harm? — Yes
2. Is there appropriate evidence to support taking an X-ray in this case? — Yes
3. Is a decision to take an X-ray in this case supported by my clinical experience? — Yes
4. Will an X-ray significantly impact my management of this case? — Yes
5. Does the patient still consent to the investigation? — Yes
Image Distribution: I'll get images online
Referrer: Dr. Stephen Weightman #6205134Y
Pregnant: No Consent: Yes
Urgent: No
Date: 16/04/2026
Signature: _______________________