Sample clinic. Clinicians, prices, reviews and messages are examples.

Monday to Friday 8 am to 6 pm

For an emergency, call 000. For help that can wait, call us in opening hours.

14 Example Street, Fitzroy VIC 3065

03 5550 1200

Monday to Friday 8 am to 6 pm

For an emergency, call 911. For help that can wait, call us in opening hours.

250 Sample Avenue, Ottawa ON K1P 0A1

613-555-0123

How to refer

Fill in the form with your details, the patient's first name and phone number, the service and how soon. We contact the patient to book them in.

Prefer to call? Ring us on 03 5550 1200613-555-0123.

Clinical details

This form does not take clinical details. Please send them through your secure channel or by fax, not here.

What we treat

  • Physiotherapy: Help with aches, strains and stiff joints, and a plan to get you moving again.
  • Sports physio: Care for sports injuries and a steady plan to get back to training.
  • Dental check-up: A friendly check of your teeth and gums, with a clear plan for what comes next.
  • Dental hygiene: A careful clean to remove build-up, plus simple tips for keeping your mouth healthy.
  • Psychology: Talking therapy with a registered psychologist, in a calm and private room.

Referral form

About you

About the patient

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