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Self-referral form

Please complete your details here for your self-referral.

Thank you for your submission. We have received your referral and will be in contact to arrange an appointment within 2 to 3 working days.

Personal information

Do you have a support person or carer?
Do you need a translator?

If you have any questions regarding this form or need assistance in completing this form, please call us on 5122 6015.

We will be in contact with you to arrange an appointment within 2 to 3 working days of receiving this information. Please be assured that all telehealth consultations are private, confidential and adhere to the same clinical standards as face-to-face consultations at your local health service.

Your privacy

Federation University collects this information to deliver health services to you and to manage your health records. We use the Zanda clinic management platform to securely store and manage your information, so our staff can provide you with the best possible care and support.

We may share this information with relevant health professionals and service providers where it's necessary to coordinate your care or as required by law.

You are required to provide this information so we can assess your needs and deliver appropriate health services. If you choose not to provide the requested information, we may not be able to offer you the full range of health services or support.

We're committed to protecting and maintaining the privacy, accuracy and security of your information. Please refer to our clinic privacy information to find out more about how we collect, hold, use and disclose personal information.

Contact us or email privacyofficer@federation.edu.au if you have any questions.