Fertility Referral	

<== SELECT STATE ==>
<NSW> NSW	
<VIC> VIC	
<QLD> QLD	

Patient’s name	
	
Date of Referral	

	

<PtFullName>	
	
<TodaysDate>	

Partner’s name	

	

<Patient's PARTNER name>	

Reason for Referral:	

<Reason for Referral>	

Additional Patient History <== ADDITIONAL PATIENT HISTORY ==>	

<General Female Infertility> General Female Infertility	
<General Male Infertility> General Male Infertility	
<Endometriosis> Endometriosis	
<PCOS> PCOS	

	

If fertility tests have been performed by the patient, please provide your patient with copies’ of their fertility results to bring to the initial consultation.	

Referring Doctor Name	
	
Provider Number	

<DrName>	
	
<DrProviderNo>	

Referring Doctors’ Surgery Name	
	
Doctors’ Phone Number	

<Practice>	
	
<DrPhone>	

	
Signature	

	

Email referral to: gp.referrals@thefertilitycentre.com.au
To book your appointment, please call us on 1800 842 862

thefertilitycentre.com.au
TFC16 GP Referral National 22.06.2023