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









Parent or Guardian Details



Patient Details




Male
Female
Appointment Details



Clinical Details