* Mandatory fields are Asterixed.

Referring Doctor's Title

Referring Doctor's Given Name *

Referring Doctor's Last Name *

Provider Number*

Practice Name

Practice Address *

Practice Suburb *

Telephone (work)*

Telephone (Mobile)

Email Address *

Preferred Method of Contact

Reason for Referral *


Preferred Doctor

Would you like the mobile number of your preferred surgeon texted to your mobile to allow immediate chat?

Patient's Given Name *

Patient's Last Name *

Patient's Contact Number (Mobile Preferred)*

Provide a brief description of the reason for your referral*

Please type the letters and numbers above.

Our goal is to tailor our services to your requirements to most effectively assist you and your patients.
We appreciate your referral and one of our surgeons is always available for a one-to-one discussion as required.

Please call 1300 265 666 and ask to speak directly with a colorectal surgeon if you need to discuss any urgent matter or if your patient requires a more urgent appointment.

Alternately a written referral can be made and below is a referral form that is quick & easy to fill out:

GP Referral Form 630KB