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John Flynn Private Hospital
Suite 5A, Medical Centre, 42 Inland Drive, Tugun, QLD 4224
Robina Private Hospital
1 Bayberry Lane, Robina QLD 4226
07 5690 1727
07 5676 6565
info@gcrehab.com.au
Mon to Fri
9:00 am - 5:00 pm
Refer a
Patient
Inpatient Rehabilitation Referral Form
Referring site information
Referring hospital
Bed / ward number
Patient ID number
Admission date
DD slash MM slash YYYY
Contact person
Contact person's phone number
Referrer information
Title
Ms
Mrs
Mr
Dr
A/Prof
Prof
Other
First Name
(Required)
Last Name
(Required)
Provider number
(Required)
Provider qualification
Addiction medicine
Anaesthetist
Cardio-thoracic surgeon
Cardiologist
Emergency physician
Endocrinologist
Gastroenterologist
General Practitioner
Geriatrician
Neurologist
Neurosurgeon
Obstetrician and gynaecologist
Oncologist
Orthopaedic surgeon
Otolaryngologist
Oral and maxillofacial surgeon
Pain medicine physician
Palliative medicine physician
Respiratory and sleep medicine physician
Rheumatologist
Rehabilitation physician
Sport and exercise physician
Urologist
Vascular surgeon
Other
If other qualification, please enter here
(Required)
I would like to be kept informed by
(Required)
Email
Phone
Practice phone number
(Required)
Practice name
Email Address
(Required)
(Practice) Street Address
(Required)
City
(Required)
State
(Required)
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
(Required)
If this referral is being completed by a registrar or intern, details of the referring consultant must be provided below
Consultant first name
Consultant last name
Consultant Provider Number
Patient Information
First name
(Required)
Last name
(Required)
Date of Birth
(Required)
DD slash MM slash YYYY
Medicare number
Medicare Reference Number
Valid to (MM/YYYY)
Patient phone number
(Required)
Patient Email
Patient address
City
State
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
Funding source
Funding Source
Private Health Fund
DVA
Workers Compensation
Self-funded
Other
Health Fund Name
Policy number
Referral Information
Consent
(Required)
The patient is aware of the referral and agrees to be contacted
(Required)
Reason for referral
(Required)
Diagnosis
Patient goals
Current mobility
Past medical history
Upload referral letter, if needed
Max. file size: 10 MB.
Submission of an online referral does not does not automatically constitute acceptance of the referral. We will contact your patient, and you will be advised of the outcome.
Signature
(Required)
Memberships & Accreditations:
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Make an appointment
Book your first visit at GC Rehab through the following form, and we will contact you to arrange a date and time.
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Email
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Phone
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privacy policy
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07 5690 1727
07 5676 6565
info@gcrehab.com.au
Mon to Fri
9:00 am - 5:00 pm
John Flynn Private Hospital
Suite 5A, Medical Centre, 42 Inland Drive, Tugun, QLD 4224
Robina Private Hospital
1 Bayberry Lane, Robina QLD 4226
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