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

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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

    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