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