Back to referrer informationFor GPs & Referrers

Request an appointment for a patient.

Submit the referrer, patient and referral details below. Our practice team will review the request and contact the referring practice or patient as appropriate. This is an appointment request, not an online booking, and submission does not confirm an appointment.

Prefer paper or fax? Download the referral template PDF, email referral documentation to admin@colonsurgery.net or fax 03 8677 5417.

Referrer Details

Referrer name

Practice name

Provider number

Telephone

Format: 03 9081 7757 or 0412 345 678

Patient Details

Patient name

Date of birth

Patient telephone

Format: 03 9081 7757 or 0412 345 678

Patient email(optional)

Referral Details

Referral reason

Clinical priority

Additional clinical information(optional)

Supporting referral letters, pathology, imaging and procedure reports may be sent to admin@colonsurgery.net or faxed to 03 8677 5417.

I confirm that I am authorised to submit this appointment request and that the information provided is necessary for arranging the patient’s care.

This form is not for emergencies or clinical deterioration. Patients requiring urgent medical attention should attend the nearest Emergency Department or Cabrini Emergency Department. Submission does not confirm an appointment; our practice team will review the request and make contact.

The details submitted are collected to review and coordinate the referral. The required details are needed to assess it. Hosting, bot-verification and email providers support this form and may process information outside Australia. Information is handled in accordance with the Privacy Policy.