referral form

For Medicare purposes referrals to MHCK need to be made by your treating physician (General Practitioner or Specialist).

If you prefer to fax please download a PDF version of our form here and fax it through to: (03) 93456580

Patient Details

Name*
Address*
Date Of Birth*
Day
Month
Year
Phone Number*
Email*

Clinical History

Investigations Requested (please tick)

Requesting Doctor

Referring Dr*
Provider Number*
Phone Number*
Clinic Name*
Date*
Day
Month
Year