You can fill out this online form and our reception staff will contact you to offer an appointment.

This website uses SSL security however to increase your data protection we recommend using a private internet connection and not completing the form via a public WiFi.

Alternately you can send your referral via fax or email. Please make sure attachments are sent via online form or email.

Paediatric Gastroenterology Victoria
T    03 9345 6644
F     03 8888 9944
E    admin@paediatricgastro.com.au

    Child Details

    Parent Details

    Request an appointment with

    Please select one type of practitioner appointment per form filled

    Request for Telehealth (See Services - Telehealth for more information)

    Patient history and recent investigation results

    Include relevant investigation results below or attach to this form, email or fax us the information. Please note there is a 2MB file upload limit. For large files, email it to us directly.

    Referring Doctor Details

    Required for medical appointments only

    Yes, I have a care plan from my doctor for medicare

    Yes, I have private health insurance