Referral Request Form

Today's date

I understand that this online form is to request a repeat of a referral to a specialist I need to see at regular intervals that has been established in a prior consultation with my medical practitioner. *

I understand that the turnaround time will be on a best-efforts basis and will depend on my practitioner's working days, availability, and the potential complexity of my request. *

If you are seeking a Mental Health Care Plan (MHCP) / Review or an Enhanced Primary Care Plan (EPC) / Review - please do NOT complete this form. MHCP/EPC requests require an appointment. Kindly schedule a 30-minute follow-up with your practitioner using the link HERE or contact the clinic directly on (02) 8311 2800.

Patient First Name *

Patient Last Name *

Patient Date of Birth *

I am completing this form on behalf of my child / ward

Parent / Guardian First Name *

Parent / Guardian Last Name *

AgeCalculation

AgeCalculation16

Email Address *

Mobile Number *

Patient has an Australian Medicare Card *

YesNo

Medicare Card Number (10 digits) *

Medicare Card Reference (Number before patient name) *

Medicare Card Expiry *

Patient of: *

Please specify the name of the Doctor *

I agree for my card entered below to be charged the referral request fee of $58 prior to my referral being issued. *

I acknowledge my referral request may not be granted upon review of my file by my doctor and an appointment may be required (in such case, the referral request fee will be refunded). *

Type of Specialist Required *

Specific Referral Requirements *

I can provide contact details of the Specialist to be referred to.

Specialist Name *

Specialist Address *

Street address *Street address line 2

City *

State *

Postcode *

Specialist Contact Number *

Specialist Fax Number (if known)

Specialist Email Address (if known)

Comments (optional)

Payment Details

Referral Request Payment Fee *