1300 883 560

GP Referral Form

Note that your patient needs a referral to Dr Ameratunga as well as her partner in fertility cases.

If your practice has ‘Medical Objects’, then referrals can be made through this System (and all relevant investigations can be downloaded).

You can also complete the form below and/or attach a referral letter or electronically signed letter, or send the original letter with your patient.

Alternatively, your administration staff can fax or email the referral to our staff

  • Fax: (07) 3154 6360
  • Tel No: 1300 883 560

Patient Information

First Name
Last Name
Title
Address
City
State
Postcode
Home Phone
Mobile Phone
Date Of Birth

Referring Doctor Information

First Name
Last Name
Provider Number
Phone
E mail
Fax
Duration of Referral
Urgent
 Yes No 

Presenting Problem

Attachment