• This form is for use by healthcare professionals.

    If you experience a problem submitting this form and are using the Microsoft Edge browser, we recommend switching to Google Chrome or speaking to your IT Administrator. Alternatively, contact our patient triage team on 1800 620 420 Mon-Fri 8:30am-5pm AEST to discuss the referral.

  • Please note:

    Our Health Services Teams will be attending a professional development workshop on 27th and 28th October 2026. The team will action your referral when they return, although this may not be immediately. If your request is a medical emergency, please contact your treating team or 000.

    If you need urgent financial support, please note the Leukaemia Foundation is not a crisis service.

  • Your details (healthcare professional)

  • Format: (00) 0000-0000.
  • Are you a:

  • Patient details

  • Format: (00) 0000-0000.
  • Date of birth
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    2 digit day, 2 digit month, 4 digit year
  • Is the patient a minor?*
  • Diagnosis*
  • Could you tell us which services the patient may be interested in? (tick all that apply)

  • By clicking 'I agree' and submitting this form below, you acknowledge that consent was obtained from the patient or parent/caregiver to complete this referral on their behalf. Additionally, both you and the patient or parent/caregiver consent to your details being used by the Leukaemia Foundation to make contact about relevant blood cancer services and information.You also consent to the Leukaemia Foundation’s Terms of Use, Privacy Commitment and Privacy Notification Statement.

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    If you experience a problem submitting this form and are using the Microsoft Edge browser, we recommend switching to Google Chrome or speaking to your IT Administrator. Alternatively, contact our patient triage team on 1800 620 420 Mon-Fri 8:30am-5pm AEST to discuss the referral.

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