General Referral Form

Please use this form if you are NOT a GP to refer your client / employee for this service.
Person referring*
Referrer’s Name*
First Last
Referrer’s Organisation*
Reason / Instructions for Referral
- Confirm medical diagnosis
- Confirm medical treatment options
Other Reason / Instruction for Referral
Upload Supporting Documents
Drop files here or
Accepted file types: doc, docx, pdf, jpg, gif, png.
Maximum file size - 2Mb, maximum allowed files - 5
Service Account's Payer's Name*
First Last
Service Account's Payer's Contact Number*
Worker / Employee Name*
First Last
Worker / Employee Date of Birth*
Worker / Employee Address*
Street Address Suburb State Post Code
Worker / Employee Contact Number*
Claim number (optional)
Name of Agent / Self Insurer (optional)*
Nature of specialist(s) referring to*
- Neurosurgeon
- Neurologist
- Rheumatologist
- Psychiatrist
- Orthopaedic
- Occupational Medicine
- Pain and Rehabilitation Medicine
Treating GP Name*
First Last
Treating GP Address*
Street Address Suburb State Post Code
GP Contact Number*
E-mail me a copy of this form*
Email address to send copy of form to*