Request a Specialist Referral

Referral

Personal

Payment

Referral Details

Preferred Consultation Time *

Within 2 hours

Within 4 hours

Within 8 hours

Within 24 hours

If submitted after 18:00, your request will be processed the next day at first available

Specialist type *

Reason for referral *

Are you taking medications? *

Yes

Any existing medical conditions? *

Yes

Upload Supporting Documents (Optional)

Upload doctor referral, previous imaging reports, or medical records. Accepted formats: PDF, Word (docx), Excel (xlsx), PNG, JPG (Max 5MB per file)

Drag & drop files here or click to select files

I acknowledge that: *

I have read and agree to the Terms and Conditions.
This is not a medical emergency - for emergencies, call 000.
Telehealth has limitations compared to in-person care and may not be appropriate for all conditions.
I will see a doctor face to face if my condition doesn't improve.
All information I have provided is true, accurate and complete to the best of my knowledge.

Personal Details

First Name *

Surname *

D.O.B *

Gender *

Mobile *

Email *

Street Address *

City *

State *

Post Code *

Payment Information

Secured by Tyro

Step 3 of 3

tyro

Payment Gateway

Specialist Referral Fee $49.00

Total to Pay $49.00 AUD

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Expiry Month

Expiry Year

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