Online referral Requests

Patients of Berwick Healthcare who require a repeat referral can order it by filling in the below details. Fill in the name of the specialist and when your next appointment is with them. Allow 48 hours for the referrals to be actioned by your doctor.

If you require your referral sooner, please contact the clinic to arrange an appointment. A charge of $15 or ($15.69 if you use paypal) is required for all referrals, this can be paid for by PayPal or at reception on collection.

Please note only referrals previously written by your doctor can be requested.

First Name

Last Name

Date of Birth

Medicare or OSHC number

Phone Number

Address

E-mail

Full Name of Specialist you're requesting

Address of Specialist you're requesting

Your next appointment with the specialist?

I agree that I am a patient of Berwick Healthcare

Yes

I confirm I am the above patient requesting this referral. Or the parent or guardian of a child under 16 or within my care

Yes

Have you been referred to see this specialist before?

Yes

I understand that this request is up to the doctor's discretion and my doctor may decline request due to medical reasons

Yes

I agree to have my e-mail saved with the Berwick Healthcare data base for future practice information and updates

Yes

By Communicating electronically with Berwick Healthcare, I dismiss the practice from all claims, losses, expenses and liabilities caused by any problems in using electronic mail with the risk of interception by third parties and non-recipients.

I Agree

Online referral Requests

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