Referral Form

Please use the following form to send a referral to Star Health.


Referrer Details

Referrer Name*

Referrer Organisation*

Referrer Position*

Referrer Phone*

Referrer Email*

Referrer Fax



Client Details

Client Family Name*

Client Given Names*

Client Date Of Birth (dd/mm/yyyy)*

Client Gender*

Client Home Address*

Client Contact Phone Number*

Client Country of Birth*

Is the client of Aboriginal or Torres Straight Islander origin?*

Does the client have a refugee status?*

Does the client require an interpreter?*

If yes, please state preferred language

Is the client living in insecure housing?*

Client Medicare Number* (Enter NA if not available)

Please give details of the client's current GP (GP name, Practice name, Address, Phone)*

Does the client hold any of the following concession cards?*

Please outline your reason for referral*

Please tick below if you have an Assessment and/or Care Plan and would be happy for Star Health to contact you to obtain a copy. Alternatively, you can attach them below.
AssessmentCare Plan
Please attach an Assessment and/or a Care Plan if available

Does the client give consent to a referral to Star Health?*