GPs - Close a Referral

For General Practitioners - Close a Referral

Click on the Health Professionals tab (above) and submit the form, or contact us on 03 5320 4221. Find out more about Specialist Outpatients clinics at Grampians Health Ballarat.

General Practitioners - Close a Referral

Submit this form or alternatively contact us on 03 5320 4221.

To ensure optimal medical care and for privacy reasons, medical advice cannot be provided via email.

GP name *

GP practice *

GP address *

GP phone number *

Date *

Patient name *

Patient address *

Patient DOB *

Specialty service original referred to *

Date of original referral

Reason/condition for original referral *

Further information

Consent for storing submitted data *

Yes, I give permission to store and process my data

1 Drummond Street North
Ballarat VIC 3350

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