Patient Referral Upload

For new patients of The Children’s Private Medical Group a referral needs to be received before an appointment can be made. Please upload the referral using the file upload section below.

Patient refers to the child that will undergo consultation and/or treatment.

Patient Details

First name *

Middle name

Last name *

Preferred name

Parent or Guardian Details

First name *

Last name *

Email Address *

Mobile Phone *

Home phone

Referral Upload

Please ensure the file attachment size is no larger than 5mb.

Attach File *

Upload another file

Attach File 2

Upload another file

Attach File 3

Upload another file

Attach File 4

Clinical condition / Referral question

Paediatric Medical Providers

Allied Health

Patient Details

Parent or Guardian Details

Referral Upload