Get in touch: (02) 4288 8001

Specialist / GP Referral & Appointment Request

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Specialist / GP Referrals


Our medical referral / appointment request form can be used by Specialists, GPs, and Patients.  It acts as either a Medical Referral or Appointment request.  We will respond to your request within 12 hours.
 
Alternatively appointments can made by phoning our clinic on:
Shellharbour (02) 4288 8001
 
Referrals are needed for Workers Compensation, Insurance Claims and GP referred Care plans.  Please contact our office if you do not have your referral before your appointment.  Referrals are NOT required for private patients.
 
 
 


Appointment Request

You are welcome to complete the following form and we will contact you within 12-24 hours to schedule an appointment.



Personal Details

First Name: *
Surname: *
Date of Birth:
Email: *
Contact Number: *
Injury Details:



GP Details

GP Name: *
GP Location/Clinic: *



Referral Details

Type of Appointment: WC TPI MVA EPC care plan Private
Do you have a referral?: Yes No
(Please note: Private patients do not need a referral)



Insurance Details (Only Applicable for Insurance Patients)

Insurance Company:

Claim Number: Case Manager:

Employer:
Contact Person: Contact Number: