Refer a Patient

Before you continue

This referral form is intended for registered medical practitioners and their clinic staff, referring a patient in their care. It isn't intended for patients to submit on their own behalf — if you're a patient wanting to see Dr Chour, please ask your GP or specialist for a referral, or use our general enquiry form instead.

I confirm I am a registered medical practitioner, or a member of clinic staff acting on their behalf, submitting this referral for a patient in my/our care.

A note on how this works. This form generates the referral PDF entirely in your browser — nothing is sent anywhere until you choose an action below. Downloading the PDF keeps everything local to your device, so you can attach it to your own secure referral system (HealthLink, Argus, Medical-Objects, or secure fax). Emailing it from this page is a convenience option for lower-sensitivity requests — like the practice's main enquiry form, it isn't a secure clinical messaging channel, so for referrals containing detailed patient health information, downloading and sending via HealthLink or fax remains the safer choice.

1Referring practitioner

Full name

Practice / clinic name

Provider number Please enter a valid 8-character provider number (6 digits + 2 letters/numbers).

Phone

Email (for our reply / report)

Fax (optional)

2Patient details

Full name

Date of birth

Medicare number

Patient contact phone

Patient contact email (optional)

3Referral details

Procedure or consultation of interest

Reason for referral / relevant clinical history

Relevant imaging already performed (type, date, location)

Current medications, particularly anticoagulants / antiplatelets See our anticoagulation guide if relevant to the planned procedure.

Urgency

Routine Semi-urgent Urgent

Additional notes (optional)

4Attachments

Please don't attach large imaging files (DICOM, CD exports) here — send these separately via HealthLink, secure upload, or your usual imaging transfer method. You can attach a single supporting document below if needed (e.g. an existing referral letter or key report, max ~5MB).

Supporting document (optional)

Emailed referrals are sent to admin@interventional.com.au with the PDF attached. For your records, downloading the PDF first is recommended regardless of which option you use to send it.

Privacy note

This form does not store any data on our server — the PDF is generated locally in your browser. If you choose to email the referral from this page, the information you've entered (including any patient details) is transmitted via FormSubmit, a third-party form-to-email service, in the same way as our general enquiry form. This is a reasonable channel for routine, lower-sensitivity referrals, but is not an accredited secure clinical messaging system. For referrals containing detailed patient health information, we recommend downloading the PDF and sending it via HealthLink, Argus, Medical-Objects, or secure fax instead.