Specialist Referrals

Reason for Referral

Purpose: Please provide details of your health concern and why you believe a referral is needed. A licensed practitioner will assess your request and determine if a referral is appropriate. This form does not guarantee that a referral will be issued.

Which specialist are you requesting a referral to? *

What is the medical concern or condition you are seeking help for? *

Have you seen this specialist or another about this issue before? *

Yes No

If yes, please provide details (name, clinic, approximate date):

Relevant Medical History

Note: Accurate medical history helps our team assess the necessity and urgency of your referral. Please include only what is relevant to your request.

Do you have any current or chronic health conditions? *

Please list any medications you are currently taking:

Do you have any relevant test results or past investigations?

Yes No

If yes, describe the test or investigation (e.g. MRI, blood test, etc.):

Referral Urgency & Details

Urgency: Your responses will help the clinician prioritise your referral. Please be honest — urgent referrals will be considered when medically appropriate.

How soon do you need to see the specialist? *

As soon as possible In the next few weeks No specific urgency

Have you been referred for this condition before?

Yes No

Is there anything else we should know to support your referral?

Please tell us briefly what brings you to see the doctor today. *

Consent & Signature

Final Consent: I confirm the information I have provided is accurate. I understand that a referral may only be issued if clinically appropriate. I acknowledge that a doctor may contact me for more information before issuing a referral.

Acknowledgement of Accurate Details *

I declare that the personal information provided is true and correct, and acknowledge that providing false or incomplete details may result in delays or denial of prescriptions, documentation, or appointments.

Signature *

Confirm Your Details

We’ll use your email to match your booking. Please enter your Medicare number to confirm.

Email *

Medicare Number *

Medicare Reference *

Get Your Specialist Referral

Reason for Referral

Which specialist are you requesting a referral to? *

What is the medical concern or condition you are seeking help for? *

Have you seen this specialist or another about this issue before? *

If yes, please provide details (name, clinic, approximate date):

Relevant Medical History

Do you have any current or chronic health conditions? *

Please list any medications you are currently taking:

Do you have any relevant test results or past investigations?

If yes, describe the test or investigation (e.g. MRI, blood test, etc.):

Referral Urgency & Details

How soon do you need to see the specialist? *

Have you been referred for this condition before?

Is there anything else we should know to support your referral?

Please tell us briefly what brings you to see the doctor today. *

Consent & Signature

Acknowledgement of Accurate Details *

Signature *

Confirm Your Details