Patient Referral

Patients may be referred to practitioners at The Children’s Private Medical Group by faxing a referral to 9345 6100 or by using this form. Please complete all mandatory fields, enter the referral details in the space provided and upload any relevant investigations in the file upload section.

Alternatively, use the Patient Referral Upload form.

Please note: items marked * indicate mandatory fields. Patient refers to the child that will undergo consultation and/or treatment.

Referring Doctor Details

GP Name *

GP Practice Name

GP Provider # *

Address

Suburb

State

Postcode

Phone *

Email Address *

Parent or Guardian Details

First name *

Last name *

Phone *

Patient Details

First name *

Last name *

Date of Birth *

Gender *
Male
Female

Appointment Details

Referred to *

Urgency *

Referral Duration *

Clinical Details

Clinical condition / Referral question *

Attach File (250Mb Limit *)

Prove you're not a robot *