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Self-referral form

Please complete your details here for your self-referral.

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.

You can find more information about your privacy here.