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.
GP Clinic Name:
GP Contact Number:
Patient's Date of Birth:
Patient's Contact Number:
Medication(s) of Concern:
Eugeroics (wake-promoting medication)
Sedative-hypnotics ('Z drugs')
Consent Obtained for Referral
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. Please contact me directly.
How did you hear about us?
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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