Child’s Referral Form

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Child's Details

First name

Family name or surname

Date of birth

MaleFemale

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?

MotherFatherOther

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

Email address 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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