JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
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 2-3 business days. We will also advise you once we have made contact with your patient.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
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
Suburb or postcode where client currently lives:
Your answer
Medication(s) of Concern:
*
Opioid analgesics
Non-opioid analgesics
Benzodiazepines
Eugeroics (wake-promoting medication)
Sedative-hypnotics ('Z drugs')
Other
Unsure/unknown
Required
Consent Obtained for Referral
*
*Please note: we can't proceed with referrals if the client hasn't provided consent. To speak with us about this, call 1800 931 101
Yes - my patient has provided informed consent and would like the MSRS Intake Worker to contact them directly.
No - my patient has not provided informed consent for the referral.
Required
Is the patient at risk of harm to self or others?
Yes
No
Clear selection
If yes, please provide details:
Your answer
Does your patient require an interpreter?
Yes
No
Clear selection
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 2-3 business days and advise you of the referral outcome.
A copy of your responses will be emailed to the address you provided.
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
Forms
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
Terms of Service
Privacy Policy