For Doctors

Fill out the form below to refer a patient to PainMedSA

Patient Referral

Fields marked with * are mandatory.

All medical referrals are triaged by medical staff and our administration team will contact your patient direct.

Please note that our practitioners are not presently accepting Motor Vehicle Accident (MVA) claims, interstate WorkCover claims and are unable to refer uninsured patients into the Public system.

"*" indicates required fields

GP/Specialist details

Referring Doctor Name*

Referring Doctor Practice Name*

Referring Doctor Provider Number*

Type of Specialist*

Address

Street Address Address Line 2 City State Postcode

Referring Doctor phone*

Referring Practice email*

Referred to*

Patient details

Patients Name*

First Last

Patient Date of Birth*

Patient email*

Patient phone*

Patient clinical condition / details*

Upload referral document/s

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 4 MB.

Comments

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For Doctors

Fill out the form below to refer a patient to PainMedSA

Patient Referral

GP/Specialist details

Patient details

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