Referrals

Referrals can be mailed, emailed or faxed to our office. Alternately, doctors and/or patients can use the following form and the patient will be contacted as soon as possible.

Child Details

Parent Details

Request an appointment with

Please select one type of practitioner appointment per form filled

Request for Telehealth (See Services - Telehealth for more information)

Patient history and recent investigation results

Include relevant investigation results below or attach to this form, email or fax us the information. Please note there is a 2MB file upload limit. For large files, email it to us directly.

Referring Doctor Details

Required for medical appointments only


Yes, I have a care plan from my doctor for medicare

Yes, I have private health insurance