• 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)

  • Patient details

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  • 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.

  • Christmas closure information, Please Read.

    Leukaemia Foundation Offices are now closed and will re-open again on Monday, 5 January 2026.

    Any referrals received will now be reviewed by our Health Services Team when we return on Monday, 5 January 2026.

    We would like to take this opportunity to thank you for your ongoing support and wish you and your loved ones a safe festive season.

    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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