REFERRAL FORM

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REFERRAL FORM (FOR REFERRING DOCTORS ONLY)

* Indicates required field

Patient Name *

First

Last

Patient Date of Birth (DOB) *

Phone Number *

Email *

Clinic Location *

Fairfield, QLD 4103 Mackay/ Whitsunday Region (Dr Geffen only)

Previous Relevant Medical History *

Practitioner *

Dr Saul Geffen (Rehabilitation Physician) Dr Saul Geffen (Rehabilitation Physician - Central QLD) Dr Ben Manion (Pain & Rehabilitation Physician) Dr Mostyn Yong (Rehabilitation Physician) Dr Harminder Sarai (Rehabilitation Physician) Dr Gaj Panagoda (Paediatric Rehabilitation Physician) Dr Angela Wills (Rehabilitation Physician) Prof. Michael O'Sullivan (Neurologist) Jean Clow (Occupational Therapist) Nathan Craig (Physiotherapist) Steve McCosker (Psychologist) Kellie Forrest (Psychologist)

Reason for Referral? *

Current Medication (if any): *

Previous Investigations: *

Please provide any radiology, pathology or relevant information

Current Treating Doctor *

Treating Doctor Provider Number *

n/a if not applicable

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Contact us

QRS Head Office
75 Brougham Street
Fairfield QLD 4103
Phone: 07 3393 2001 | Fax: 07 3393 2002
Email: [email protected]

OUR WIDE RANGE OF SERVICES:
REHABILITATION MEDICINE
PAIN MEDICINE
PAEDIATRIC REHABILITATION MEDICINE
NEUROLOGY
PHYSIOTHERAPY
PSYCHOLOGY
OCCUPATIONAL THERAPY
MEDICOLEGAL ASSESSMENTS

LOCATION:
75 BROUGHAM ST,
FAIRFIELD QLD 4103

CONTACT US:
PHONE: 07 3393 2001
FAX: 07 3393 2002
EMAIL: [email protected]

OPENING HOURS:
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY

8.00am - 5.00pm
8.00am - 5.00pm
8.00am - 5.00pm
8.00am - 5.00pm
8.00am - 3.00pm
CLOSED
CLOSED

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