Referral Form

If you are a health professional and would like to refer to us, please fill in this Referral Form.

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 Strait 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 select the type of service you’d like the client referred to:*

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?*


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