Referral Enquiry

This form is for enquiries about an existing referral provided to you within the last 12 months - including requests for a copy if it's been misplaced, or if you were told one would be sent but haven't received it.

You may be eligible for a repeat referral without an appointment if it expired within the past 6 months. Request one via our portal here.

You'll need to book an appointment with your GP for a new referral.

Please allow up to 3 business days for a response to your enquiry.

PATIENT DETAILS

Date of Submission

First Name *

Last Name *

Date of Birth *

Contact Phone Number *

Email Verification *

Send code

ENQUIRY DETAILS

What does your enquiry relate to? *

Please provide us with some more information about your enquiry

What is the name of the specialist you were originally referred to

On which date did you receive your original referral *

DETAILS OF NEW SPECIALIST

If you are requesting a change of specialist name, please provide name and contact detials of the alternative specialist below

Name of New Specialist

Specialist Email Address

Specialist Phone Number

Specialist Fax Number

Specialist Street Address

Signature *

Clear

Date