3D Render Request

1 Patient & Doctor Details

2 Scan Details

3 Imaging Request

4 Consent

Patient ID*
Patient Details
Patient Name*
First Name/s Surname
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Date of Birth*

DD
MM
YYYY
Preferred phone number*
Email*
Referring Doctor Details
Referring Doctor*
Provider No.*
Phone*
Email*

Has your diagnostic scan already been performed?*
- Yes
- No
We require access to your completed scan before we can assess your 3D Render request. Please continue with the request form, you can provide us with your scan details later, once your scan is completed.
Date of scan*

DD
MM
YYYY
Radiology Practice Details
IMPORTANT

We require the contact details of the exact location of the radiology practice that performed your scan. This will be used to retrieve your scan data and build your 3D render.
Radiology Practice Name*
Address*
Street Address City / Suburb State / Province / Region ZIP / Postal Code Country
Phone*
Email
Consent to access scan data*
I hereby authorise 3D Medical Render to obtain my scan data.

Clinical Details
Upload Referral / Request form*
Smartphone photo of your form accepted.
Drop files here or
In addition to your referring doctor, list any other health practitioners to receive your 3D Render
Name of practitioner Type of practitioner Email Address

Quote
Will this be a Workers Compensation, Third Party Insurance or Veterans Affairs claim?
- Yes
- No
Claim Type*
- Workers Compensation
- Third Party Insurer
- Veteran Affairs
Claim Number
Insurer Name*
Insurer billing address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurer Email
Insurer Phone
DVA Card Type*
- Veteran Card
- Veteran Gold Card
- Veteran White Card
DVA Card Number*
Payment Approval Letter
Drop files here or
Our baseline fee is $300 AUD but this can vary. Please see Pricing for further information.
Any Workers Compensation, 3rd Party insurance or Veterans Affairs claims require a specific letter of approval from the insurer or agency before any rendering work commences. We will send your referring doctor a quote for the purpose of obtaining this approval letter. Once your doctor has send us approval from your insurer, you will be notified that work has commenced.
Consent to Email
IMPORTANT

Your 3D rendered images will be emailed directly to the surgeon (and any other health practitioner that you nominate as directly involved with your care). This allows colour images that are best appreciated on computer screens to be rapidly and conveniently delivered. As these images will form a component of your personal health record, you should be aware that the use of standard email constitutes a potential risk to medical confidentiality. The internet is not secure or private, and it is therefore possible that unauthorised people could intercept, read and possibly modify any e-mail that is sent. This means that we cannot guarantee confidentiality.

By submitting this request to process your medical imaging data, you agree that e-mail is not a confidential method of communication and accept that 3D Medical Render will not be liable in the event of any 3rd party inappropriately using or accessing images forwarded by e-mail. You furthermore agree that 3D Medical Render will not be liable for any improper disclosure of your health information that has not occurred by intentional misconduct. You hereby consent to 3D Medical Render, at its discretion, communicating your medical images to your referring physician or members of his/her staff, or where appropriate other health practitioners directly involved with your care, by means of standard non-encrypted email.
Consent to Email*
I consent to my 3D rendered images being delivered by email.

Name of practitioner	Type of practitioner	Email Address

Patient Details

Referring Doctor Details

Radiology Practice Details

IMPORTANT

Clinical Details

Quote

Consent to Email

IMPORTANT