Patient Referral Form

"*" indicates required fields

Are you an existing patient of WA Psychiatry and ADHD Clinic?*

Yes

First Name*

Last Name*

Date of Birth*

Mobile Number*

Email*

Medicare number*

Medicare Card reference number*

Please enter a number from 0 to 9.

Medicare Card Expiry*

If you do not have a Medicare card at this time, please enter all "111 or 000" into the required space

I consent to have my appointments conducted via telehealth.

Select the doctor your referral is directed to*

Upload Referral letter*

Accepted file types: pdf, docx, doc, jpg, Max. file size: 10 MB.