Doctor Referral form

Referring Doctor: This form only needs to be completed for the first consultation of the patient. Subsequent medical reviews by our Medical team do not require a referral form. This referral is valid for 24 months.

1. Referral Details

I would like a referral pad sent to the address above.

2. Patient Details

I certify that the information in this form is true and correct.

Privacy Note: The information contained in this application is protected by law from unauthorised access and misuse. The information will only be accessed by health service staff directly involved in providing services to the applicant, or with other lawful excuse.

"If you would like a hard copy of our online referral form we can send out a paper pad so you can provide to your patients. Just select the relevant tick box on the bottom of this referral form or you can contact us via email on or call us on 1300 217 405 and ask for a referral pad to be posted out to you".