Refer a Patient

Complete this form in place of the printed referral. Dr Iyer triages all referrals within 24–48 hours of receipt.

Patient Details

Full name

Date of birth

Gender

Address

Phone

Medicare number

Private health fund & membership no.

DVA file number (if applicable)

Referring Practitioner Details

Doctor name

Practice name

Provider number

Practice phone

Secure email (Medical Objects / HealthLink or practice email)

Referral validity

Preferred Consulting Location

Sunnybank Specialist CentreMedSN Greenslopes

Clinical Reason for Referral & History

Primary diagnosis / presenting issue

Relevant past medical & surgical history

Current medications / allergies

Select Clinical Pathway

NeuroRestore: post-stroke, TBI, Parkinson's, MS, spasticity & gait/balanceBackAlign: chronic spinal pain, sciatica, stenosis, post-surgical painJointPrep: pre-operative conditioning & post-op orthopaedic recoveryActiVate: post-ICU, acute hospital deconditioning, frailty & fatigueGeneral rehab: comprehensive specialist medical evaluation & coordination

Attachments: clinical summary, pathology, imaging, medication list. Please email these separately to admin@newhoperehab.com.au.

We collect the information on this form to assess and coordinate your rehabilitation care, including sharing relevant details with your treating doctors and, where applicable, your health fund or insurer. We store submissions securely in Australia. See our Privacy Policy for details on how your information is handled and your rights to access or correct it.

I have read the notice above and consent to New Hope Rehabilitation collecting and using my information as described.

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