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?
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?
Primary Contact:

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City
State
PostCode
Email
example@example.com
Phone Number
Format: 0000 000 000.
Additional Contact:

PrefixFirst NameMiddle NameLast Name
Relationship:
Email
example@example.com
Phone Number
Format: 0000 000 000.
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
Format: 0000 000 000.
Referrers Details
Referrer Name

PrefixFirst NameLast Name
Provider Number:
Referrer Type
Practice Address

Practice Name

Street Address

CityState / Province

Postal / Zip Code
City
State
PostCode
Referrer Email
example@example.com
Phone Number
Format: 0000 000 000.
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