Practitioner Referral

Practitioner Referral

Refer your client to The Cellular Method clinical team for blood testing and interpretation, or a doctor consult.
Practitioner Details
Practitioner full name

First NameLast Name
Business name
Practitioner email
Practitioner phone
Format: (000) 000-0000.
Client Details
Client full name

First NameMiddle NameLast Name
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Sex
Address

Street Address

Street Address Line 2
SuburbStatePost Code
Client email
Client mobile
Format: (000) 000-0000.
Postcode for blood collection
What the Client Needs
What does the client need?

Other
Reason for Referral
Reason for referral

Other
What is the client looking for specifically?
Medicare card number
Medicare reference number
Medicare expiry
Clinical Information
Health and symptoms history overview
Practitioner's assessment of this client

Cancelof
Recent blood results

Cancelof
Current medications and supplements
Allergies
Pregnant or breastfeeding
What has already been explored
Relevant context from the care plan
Consent
I confirm the client has consented to this referral and to being contacted directly by the clinical team.
I confirm the client has agreed to their results and recommendations being sent to me as their practitioner.
The client understands the fee for the selected option, and that tests not covered by Medicare and specialist tests are billed separately and quoted before ordering.
Should be Empty: