Refer a patient to Integrum

Please complete the Integrum referral form below for a full review of your patient's eligibility to participate.

First name

Last name

Patient date of birth (dd/mm/yyyy)

Patient contact number

Patient home address

See the list of eligible suburbs.

Is your patient currently receiving, or on a waitlist for, a Home Care Package?

Additional contact name

Additional contact phone number

Referrer name

Phone number

Fax number

Referrer provider number

Referrer hospital and ward (if applicable)

Is the referrer the patient's regular GP?

Patient's regular GP name