Referral Form

DR RUSSELL LAND
Suite 11, Greenslopes Specialist Centre
121 Newdegate Street
GREENSLOPES QLD 4120
Ph: 07 3847 7879 FAX: 07 3324 0488

Referral Form

Patient Details:
Name:		Address:
Home phone number:		Mobile number:
Date of Birth:
Please tick Appropriate Service:
Pelvic Mass/Ovarian Cyst/Elevated Tumour Marker		Colposcopy/Abnormal Pap Smear Management
Gynaecological Oncology (Prophylaxis/treatment)		General Gynaecology (Abnormal bleeding/post menopausal bleeding, fibroids)
Please Tick:
If you wish us to contact the patient for an appointment.
If you prefer appointment for Pindara Rooms (Gold Coast).
Comments:

Referring Doctor:
Name:		Provider Number:
Address:		Telephone Number:
This Referral has been submitted by: Dated:
The patient has consented to disclosure of above information to Dr Russell Land

NB.If the patient has recently had a blood test, x-ray, ultrasound or CT scan please either fax result to the above number or ask the patient to bring relevant information with them to the appointment.

Referral Form

Referral Form

Patient Details:

Please tick Appropriate Service:

Referring Doctor: