Date of referral

Aurora Cloud Clinic - Mental Health Web Referral

Referrer Information

Title

DrA/ProfProf

Given name *

Family name *

Provider Number *

Provider Qualification

Specify other qualification *

I would like to be kept informed by: *

EmailTelephoneFaxLetter

Practice phone number *

Practice fax number

Practice Name

Please provide your email if you wish to receive a copy of this referral submission

Would you like to be contacted about CPD education events and the hospital’s services?

If this referral is being completed by a registrar or intern, details of the referring consultant /specialist must be provided below

Consultant / Specialist given name

Consultant / Specialist family name

Consultant / Specialist Provider Number

Patient Information

Given name *

Family name *

Date of Birth *

Medicare Number

Medicare Reference Number

Patient phone number *

Patient addressStreet address line 2

City

State

Postcode

Country

Funding source

Private Health FundDVAWorkers compensationTACADFPublic-Private agreementSelf-fundedOther

Private Health Fund

Health fund policy number

DVA number

Please select card

White CardGold Card

Workers compensation claim number

Insurer

Case Manager

TAC claim number

DAN number

If other, please specify

Referral Information

The patient is aware of the referral and agrees to be contacted by Robina Private Hospital *

Reason for referral *

Upload referral letter, if needed

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If your patient is in acute crisis which presents a risk to the patient (i.e. is actively suicidal) or others, please contact your local Emergency Department. Submission of an online referral does not does not automatically constitute acceptance of the referral. We will contact your patient, and you will be advised of the outcome.

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