Referral Form

Please review our Privacy Statement before filling out the form.

Privacy Policy

Collection of your information

Information about you or your child’s medical and family history is needed to provide accurate diagnosis, treatment and to ensure we provide the highest quality of health care. We consider patient health information as confidential, and we will only collect relevant information with your consent.

Use and disclosure of your information

We work collaboratively with the school, allied health, general practitioners and subspeciality teams. To provide comprehensive assessment and care we require health information from all the stakeholders involved in the patient’s care. For this reason, with your consent/permission, health information may be shared with all the other health professionals. It is our usual practice to write to the referring general practitioner. We will send you all the copies of the referral we send out for your child which might contain sensitive information.

Limited information about the patients is provided to Medicare for billing and rebate purposes only. We may be legally bound to disclose information for example mandatory reporting of some infectious diseases, health risk or medical emergency.

Access to your information

You have the right to access your health information. You may wish to view the information or ask for a copy of a part or of the whole record provided the privacy of others is not compromised. Your child’s right to privacy of their health information might at times restrict access to this information by parents or guardians. If you find that information held is not accurate or complete, you are entitled to have that information corrected.

With your permission, your child’s health information will be made available to another health practitioner. However, you must give adequate notice for the information to be released.

Patients’ records will be kept for 7 years or until your child turns 20 years from the last point of contact (whichever is the longest) if you have ceased using our services.

Complaints

Please do not hesitate to discuss any concerns, questions or complaints about any issues relating to the privacy of your personal information with us.

    Patient's Information





    Indigenous or Torres Strait Islander descent

    Interpreter required?



    Referring GP / Eligible Midwife Information



    Referral type



    Reason for referral

    Please include clinical details, management to date, investigation results and any significant medical or social history.

    If the possibility of an autism spectrum disorder has been raised with the family or they are concerned about this possibility, please mention this in the referral.

    If the patient is a current client of Kids First Paediatrics and there has been no change in the patient’s condition but the referral has expired or a new referral has been requested, only a very brief referral (1-2 lines) is required.

    Please attach your referral letter (only txt, pdf,docx,jpg,png allowed)

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