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

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