REFERRAL FORM

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OUR PROVIDERS
FOR PATIENTS
CONTACT FORMS
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REFERRAL FORM (FOR REFERRING DOCTORS ONLY)

If you are a patient, please use the Online Contact From

* 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

Upload Referral *

Max file size: 20MB

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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]

CONTACT US:
PHONE: 07 3393 2001
FAX: 07 3393 2002
EMAIL: [email protected]
PO BOX - 8122, Wooloongabba QLD 4102

OPENING HOURS:
MONDAY - THURSDAY
FRIDAY
SATURDAY
SUNDAY

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

LOCATION: 75 BROUGHAM ST, FAIRFIELD QLD 4103

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