HP Referral

Health Professional Referral Form
Does the child your referring have an existing appointment with Wild Child Paediatrics OR have they been discussed with our Paediatrician?

YesNo
Please provide the family of your referral and ask that they register on our waitlist here:

https://wildchildpaediatrics.com/booking/paediatrician-booking/

They will be notified when appointments become available and can then book online as a priority. A copy of your referral is required to be uploaded as part of the online booking process.

Please note: we are unable to accept referrals for families without an existing booking via this link, HealthLink, or email.
Child's Name*

First NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City*
State*
PostCode*
Medicare Number:*
Including reference number
Expiry Date: Please select*
Is this child under the care of the Department of Communities - Child Protection Division?*

YesNo
Primary Contact:*

PrefixFirst NameMiddle NameLast Name
Relationship:*
Address As Above:*

YesNo
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City*
State*
PostCode*
Email*
example@example.com
Phone Number*
Additional Contact:*

PrefixFirst NameMiddle NameLast Name
Relationship:*
Email*
example@example.com
Phone Number*
Carer/ Guardian*

PrefixFirst NameLast Name
Carer Address*

Street Address

Street Address Line 2

CityState / Province

Postcode
City*
State*
PostCode*
Email*
example@example.com
Phone Number*
Referrers Details
Referrer Name*

PrefixFirst NameLast Name
Provider Number:*
Referrer Type*

SpecialistGeneral Practitioner
Practice Address*

Practice Name

Street Address

CityState / Province

Postal / Zip Code
City*
State*
PostCode*
Referrer Email*
example@example.com
Phone Number*
Referral Letter:*

Please upload referral
Cancelof
Please provide any further details:
Thank You!

Please Click here to return to Wild Child Paediatrics
Should be Empty:

Health Professional Referral Form

Referrers Details