Request a change to referral details

Please use this form if you would like your recent referral sent to a different specialist.

    First Name*:
    Date of Birth*:
    Last Name*:
    Email*:
    Doctor*:
    Date of original referral*:If your original referral is dated over 90 days ago, please contact us on 1300 557 502

    Requested change to referral:

    New specialist name*:
    Website if known:
    Address*:
    Email address if known:

    Important notes:
    1. By providing your email address above, you are giving us permission to email you a soft copy of a new referral should it be provided by your Doctor, and it not be pertaining to mental health.
    2. We will endeavour to respond to your request within 3 business days.