Refer a Patient

Referral template

Should you wish to refer a patient, please complete the online referral template below.

Once received, the referral is triaged and categorised in order of urgency. The patient will then be contacted directly with an appointment either by phone, email, SMS or a posted letter.

If the referral is urgent the referring GP/Specialist is more than welcome to contact the rooms/Adee to discuss concerns further.

ONLINE REFERRAL

Please complete relevant fields below and fax any supporting documents e.g. patient history, pathology results, radiology results etc. to F: 03 5561 4898

First Name

Address

Select a Date

Phone

Please select one or more relevant item

This patient is privately insured

I believe this is an URGENT referral

This Patient has previously been seen by another Urologist

I am referring for LUTS

I am referring for elevated PSA

I am referring for abnormal DRE

I am referring for Kidney Stones

I am the patients usual GP

I have conducted pathology investigations & faxed results to the rooms

I have conducted radiology investigations & faxed results to the rooms

This patient is an existing patient of Specialised Urology

This is an indefinite referral

Leave us a message

Referring Provider & Provider Number

Referring Practice - address & contact number

By ticking this box I am electronically signing this referral as the provider stated above. I agree to send any required patient history/relevant investigations to Specialised Urology F:03 5561 4898

Thanks for submitting!

P: 03 5561 6038

F: 03 5561 4898

Suite 9, St John of God Hospital,136 Botanic Rd WARRNAMBOOL VIC 3280