GP Referral
Please enter referral details below. You will receive a copy of the referral via email for your records.

If you have informed consent from your patient, the MSRS Intake Worker will contact your patient within two business days. We will also advise you once we have made contact with your patient.

Email address *
GP Name: *
Your answer
GP Clinic Name: *
Your answer
GP Contact Number: *
Your answer
Patient's Name *
Your answer
Patient's Date of Birth: *
MM
/
DD
/
YYYY
Patient's Contact Number: *
Your answer
Medication(s) of Concern: *
Required
Consent Obtained for Referral *
Required
How did you hear about us? *
Your answer
Thank you for your referral to the MSRS. You will receive a copy of your referral via email. The MSRS Intake Worker will contact your patient within two business days and advise you of the referral outcome.
A copy of your responses will be emailed to the address you provided.
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