Letter / referral requests.
Please complete this form for request of letters (e.g. school) or referrals (e.g. psychology, specialists.)There will be a $30 fee for using this service. This form can only be utilised if you have seen a paediatrician in the last 12 months and you have already scheduled a follow up appointment. By using this service you consent, if required, to a bulk billed video consult to clarify any details. Response time will vary from 24hrs to up to two weeks. You will be notified if an additional in rooms or Telehealth appointment is required.
Child's Name
*
First Name
Last Name
Child's date of birth
*
-
Month
-
Day
Year
Date
Parent's name
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Paediatrician
*
Please Select
Dr Dylan Wilson
Dr Naomi Chellew
Dr Stephen Ansley
Dr Garth Small
Dr Melanie Aldridge
Dr Glenn Harte
Dr Scott Blundell
Dr Catherine Stewart
Dr Syed Fasihullah
Dr Mike Wong
Dr Sarah Taylor
Dr Amy Whittaker
Dr Tim Pont
Dr David Pincus
Dr Victoria Matheson
Dr Ananya Patheja
Dr Natasha Russell
Dr Sophia Knoblanche
Dr Prudence Verry
Prof Lionel Lubitz
Dr Ravi Bala
Dr Elize O'Reilly
Dr Diane Jensen
Unknown (can not recall)
Concern
*
referral
letter
other
Comments & Requests
*
0/50
Submit
Should be Empty: