Specialist Referral Request

"*" indicates required fields

First name:*

Last name:*

Date of Birth:*

Please enter your date of birth in the format DD/MM/YYYY

Mobile Phone:*

Email:*

How would you like this repeat prescription delivered?*

I would like the request emailed to the email address on my file – $25

I would like a printed referral (pick up only) – $25

Reason for referal/main concern/is this a repeat referral:*

Have you discussed this issue with your GP previously?*

Yes

Specialty required (eg. Cardiology, Dermatology, Orthopaedics):*

Specialists contact details: (including email)

Important Information

This service is available to existing patients of the practice only.
Referrals are issued at the discretion of your doctor and must be clinically appropriate.
A referral may not be provided if you have not had a consultation within the last 6 months.
Your doctor may require you to book an appointment (telehealth or in-person) prior to issuing a referral.
Referrals are generally valid for 12 months unless otherwise specified.
Some specialists require specific information or recent investigations before accepting a referral.
A $25 administration fee applies and is payable upon submission. If the request is declined, the fee will be refunded.
Please allow up to 5 business days for processing.

Please sign:*

Todays Date:*

office use only:

request approved

request declined

appointment required