Referrers

Referrals can be sent to referrals@epilepsynetwork.com.au or faxed to 03 7066 4605. Medical practitioners can use the form below to submit an online referral.

Online referral form for medical practitioners

Referral date

Patient's First Name(Required)

Patient's Surname(Required)

Patient's D.O.B(Required)

Patient's best contact number(Required)

Patient's email address

Referring doctor's name(Required)

Referrer Provider number(Required)

Referrer practice name(Required)

Please describe the reason/s for referral(Required)

Include as much detail as possible. Please include past medical history, medications and any relevant investigations

Patient Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Untitled

Name

This field is for validation purposes and should be left unchanged.