Referrals can be mailed, emailed or faxed to our office. Alternately, doctors and/or patients can use the following form and the patient will be contacted as soon as possible.

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