Patient referral to support services for Healthcare Professionals

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.
Your details (healthcare professional)
Name*
First Name
Last Name
Organisation*
Please use the full name of your hospital or clinic - no abbreviations.
Organisaton type*
Please select the option that best describes your type of organisation
Email*
Phone Number
Are you a:

Aboriginal Liason OfficerAllied health workerGPHaematologistNursing staffOther
Patient details
Name*

First NameLast Name
Phone number*
Street Address*
Suburb / City*
State*
Postcode*
Email
Date of birth

DayMonthYear
Is the patient a minor?*

YesNo
Is the patient of Aboriginal and/or Torres Strait Islander origin?
Diagnosis*

ALLAMLAmyloidosisBlood disorder e.g. aplastic anaemiaCLLCMLHodgkin LymphomaMDSMPNMyelomaNon-Hodgkin LymphomaOther
Could you tell us which services the patient may be interested in? (tick all that apply)

AccommodationBereavement supportCarer / family supportDisease and treatment informationEmotional supportFinancial assistancePeer support groupsTransport assistanceSurvivorship supportI'm not sureOther
Do you have any additional comments in relation to this referral? You can also include contact information for a carer (if available) in this section.
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.
Yes, I agree
Yes, I would like to subscribe to receive Health Care Professional related news and updates from the Leukaemia Foundation
Please verify that you are human*
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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This form is for use by healthcare professionals.

Your details (healthcare professional)

Patient details

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.