Make A Referral

If you are a practitioner looking to refer a patient please complete the details below.

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 Name*
Patient Address*
Street Address City State / Province / Region ZIP / Postal Code
Patient Date of Birth*
DD slash MM slash YYYY
Patient Phone Number
Patient Email
Clinical History
Referring Doctor*
Provider Number*
Doctor Email*
Doctor Phone Number*
Clinic Name*
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Level 3, Suite 3.8,
48 Flemington Road
Parkville, Vic 3052