General Practitioner (GP) Referral Letter
Kids Clinic
Referring To:
*
Dr Nassar
Dr Khouri
Speech Therapist
Psychologist
Occupational Therapist
Paediatric Dietician
Child's Name
*
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
DOB
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Unit/House
Street address
Suburb
State
Postcode
Reason for seeing the Paediatrician
*
Learning Difficulties
Developmental Disorder
Speech Disorder
Behavioural problems
School Issues
Allergy/Eczema/Asthma
Constipation/Abdominal Pain
Bedwetting
Baby/Infant Check
Sleep Disorder
Growth issues
Obesity
Seizures/Abnormal Movements
Other
Please indicate any previous diagnosis:
*
Speech Delay
Developmental Delay
Asthma
Autism Spectrum Disorder
ADHD/ODD
Learning Difficulties
Anxiety
Other
Relevant medical history:
Is the child currently on medication?
Yes
No
If “Yes” pleases state :
NAME, DOSE AND FREQUENCY OF MEDICATION
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
GP Details/Provider Number
*
Dr.
Prefix
First Name
Last Name
Provider nb
Address
Street Address
Street Address Line 2
City
State
Postcode
Phone Number
*
-
Area Code
Phone Number
Email
*
Signature/Stamp
*
Submit
Should be Empty: