Patient Referral Upload

Please note: items marked * indicate mandatory fields.

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

Patient Referral Upload

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.

Patient Details
Parent or Guardian (1) Details

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

Parent or Guardian (1) Contact Details
Parent or Guardian (2) Details
Parent or Guardian (2) Contact Details
Memberships (relating to patients)
General Practitioner details
Referring Healthcare Provider Details