Make a Referral to 1300Handoc

HANDOC Patient Referral Form

Is this referral relating to an acute injury that requires immediate attention?

Yes

Please note: Online and faxed HANDOC referrals are attended to during business hours Monday to Friday, excluding public holidays. If this referral is for a patient with an acute injury requiring immediate attention, please also contact HANDOC on 1300 426 362 as soon as possible to discuss this referral with our team.

Patient Details

Prefix

First Name

Last Name

Patient address

Street address

Unit, suite or apartment (optional)

Suburb or town

State or territory

Postcode

Country

Date of Birth

Contact Number

Type of Patient

Work-related injury (WorkCover / employer claim)

Private injury – privately insured (health fund)

Private injury – self-funded (no private health insurance)

Private injury – DVA (Department of Veterans’ Affairs)

Other

Please specify other patient type

Injury & Clinical Details

Date of injury or onset of symptoms

Brief description of injury or symptoms

Attach photo(s) of injury

Choose File

Attach any relevant or additional documents

Choose File

Referrer Details

Referrer Name

Referring Facility / Company Name

Referring Facility / Company Suburb

Provider Number (for medical practitioners referring)

Contact Number

Referrer Signature

Sign here

Would you like a copy of the above information emailed to you?

Yes

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