Child’s Referral Form

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Child's Details
First name
Family name or surname
Date of birth
Child's Home Address (include region/district/country)
Family Details
Child's mother name
Child's father name
Who is the child’s primary care giver?
If ‘Other’ provide the name of the care giver
Care giver’s relationship to child (ie: grandmother, aunt, friend?)
Phone number of parents’ or care giver
What language do you speak at home?
How many children do you have?
What age are your other children?
Child’s Medical Information

We require as much medical information as you can provide.  This includes a letter of referral from your child’s doctor or surgeon, and any x-rays, blood tests, medical reports that will enable our surgeons to assess your child’s condition for surgery in Australia.

Please describe the child’s medical condition in detail.
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What treatment has the child received?
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Is the child receiving treatment now? Yes or No. If yes, please give details
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Is the child on any medication? Yes or No. If yes, what medication?
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Has the child undergone surgery? Yes or No: If yes, please provide details, and dates of surgery
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Please provide the name and contact details of the child’s treating doctor/s
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