New referral

New referral
For new appointments please complete this form. Please upload your referral (pdf). Please call to schedule an appointment: 07 5564 9668
Child's name*

First NameLast Name
Child's date of birth*
Child's medicare number*
Child's parent #1

First NameLast Name
Child's parent #2

First NameLast Name
Parent #1 Phone Number *
Please enter a valid phone number.
Parent #2 phone number
Please enter a valid phone number.
Preferred Paediatrician
Email parent #1*
example@example.com
Email parent #2
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload your referral here (pdf)*

Cancelof
Cancellation policy

1. Same-Day Cancellations
If a family cancels on the day of their appointment, they will be offered a video consult at the same fee as their scheduled review appointment in rooms.

2. If a video consult is not feasible:
The family will be booked into next available appointment, however family will be required to:

Pre-pay the usual consultation fee, and Pay a cancellation fee of:
$50 for a 30-minute review
$100 for a 1-hour new appointment
This policy is intended to reduce avoidable late cancellations and support more efficient use of clinic time across the team
Please sign that you have read our consent policy above

Clear
Should be Empty:

For new appointments please complete this form. Please upload your referral (pdf). Please call to schedule an appointment: 07 5564 9668