Online Referral Form

1. Referrals can be made immediately following surgery, injury or at any stage of treatment. Early referral is encouraged for optimal results. Referrals are usually made by the treating doctor or specialist or by other treating practitioners. Referrals can also be made by the insurer or the employer. Individuals can self-refer.
2. Patient Name(*)
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3. Patient Phone(*)
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4. Referred By(*)
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5. Referrer Phone No(*)
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   Please include area code.
6. DOB or Claim No(*)
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7. Date of Referral(*)
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8. Referrer Contact(*)
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9. Insurance Type(*)
   Workcover/Comcare
   Private Insurance
   Private Patient - No Insurance
   Other Insurance
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10. Diagnosis/Surgery Details(*)
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11. Therapy/Rehabilitation Instructions
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12. Clinic(*)
    Please Choose-------------Head Office, Hand Therapy and Occ.Health Clinic (Level 1, 62 Astor Terrace, Spring Hill)Chermside Hand Therapy Clinic (4/738 Gympie Road)Ipswich Hand Therapy Clinic (7 Pring Street, Ipswich)Mater Private Clinic - Hand Therapy (Suite 4.08, Level 4, 550 Stanley Street, South Brisbane)Carole Park Occupational Health Clinic, (148 Mica Street, Carole Park)Brisbane Airport Village Health Clinic, (Shop 7/8 Village Markets, 1-7 The Circuit,Airport Village)Springwood Occupational Health Clinic, (6/18 Dennis Road, Springwood)Invalid Input
13. Kinetic Health Group and EKCO Services(*)
    Hand Therapy
    Upper Limb Rehabilitation
    Physical Conditioning or Work Hardening
    Workplace Assessment
    Psychological Assessment
    Develop Return To Work/Suitable Duties Program
    Ergonomic Workstation Assessment
    Functional Capacity Evaluation
    ADL Assessment/Home Visit
    Preventative Training eg. manual handling, back education
    Psychological Counselling
    Vocational Assessment
    Other
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