Patient Referral Upload

Please note: items marked * indicate mandatory fields.

Patient refers to the child that will undergo consultation and/or treatment.

For new patients of The Children’s Private Medical Group a referral needs to be received before an appointment can be made. Please upload the referral using the file upload section below.

Please ensure the file attachment size is no larger than 5Mb.

Attach File (5mb Limit *)

Clinical condition / Referral question

Patient Details

First name *

Middle name

Last name *

Preferred name

Gender
Male Female

Aboriginal or Torres Strait Islander
Yes No

Date of Birth *

Country of Birth

Primary Language

Parent or Guardian (1) Details

Title *

First name *

Last name *

Occupation *

Date of Birth *

Medicare Number (10 Digits) *

Medicare IRN (Digit next to Parent or Guardian's name) *

If no Medicare number please enter '0' in Medicare Number field and '0' in Medicare IRN field.

Parent or Guardian (1) Contact Details

Address *

Suburb *

State *

Postcode *

Email Address *

Home Phone

Work Phone

Mobile Phone *

Preferred contact method *

I would like an SMS appointment reminder
Yes No

Parent or Guardian (2) Details

Title

First name

Last name

Occupation

Date of Birth

Parent or Guardian (2) Contact Details

Address

Suburb

State

Postcode

Email Address

Home Phone

Work Phone

Mobile Phone

Preferred contact method

Memberships (relating to patients)

Medicare Number (10 Digits) *

Medicare IRN (Digit next to patient’s name) *

Do you have Private Health Cover? (If yes please fill related fields) *
Yes No

Private Health Fund Name

Private Health Fund Number

Private Health Fund Reference Number

General Practitioner details

Provider Name *

Provider Address *

Provider Suburb *

Provider State *

Provider Postcode *

Provider Phone *

Referring Healthcare Provider Details

Healthcare Provider Name

Referring Healthcare Provider Phone

I give my consent to The Children’s Private Medical Group, or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my child’s care.

I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to The Children’s Private Medical Group, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010.

For more information view our Patient Information Privacy Statement.

Yes, I consent to the above – acting on behalf of the patient.

How did you hear about us

Prove you're not a robot *