GP Referral Form

PLEASE UPLOAD YOUR REFERRAL HERE

Please upload your referral document here (PDF, DOC, TIF supported): *

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Optional: Supporting documents for this referral

Supporting Document #1

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Supporting Document #2

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Supporting Document #3

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Optional: GP Details (include if not in referral letter)

First Name

Last Name

Clinic Name

Email

Phone Number

Postcode

If you use Alias please write the Alias name & surname

Patient Details

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Phone Number

Funding Type *

MedicareDVANDISNone of the above

Medicare Card No

IRN

DVA Card No

DVA Card Color

Optional: Clinician requirements (include if not in referral letter)

Specialist Required

Specialist Required - If known

Our contact Information

For any enquiries please contact us on

Phone: 03 9052 4872

Email: admin@telecare.com.au

“If your patient is actively suicidal, Telecare’s virtual care model may be insufficient for their needs. Please consider contacting the local crisis mental health team or advising them to present to the nearest Emergency Department.”

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