Submit a Referral

Complete the form below to refer a patient. Once submitted, the clinic will contact your patient directly to arrange an appointment. You will receive a password-protected PDF confirmation by email for your records.

For urgent or emergency referrals, please also call us directly on (03) 7019 3172.

Referral Submission

  • Patient Details

  • DD slash MM slash YYYY
  • If provided, the patient will also receive a copy of the referral receipt.

  • Referral Details