To assist you to deliver a safe, telehealth practice to your patients, you can send through your patient’s referral by filling out the form below.

Email or Faxed Referrals

We accept referrals faxed and emailed with your clinic details.


This form is for referring practitioners only. You may be contacted to confirm validity.

Patient Details

Referral / Request For

Referrer Details

Please include name, practice details.

No file chosen

You must check this box to submit the form