Referrals to Dr Lancashire can be made by contacting reception directly (by phone, fax or email), or by submitting the Online Patient Referral form below. On submission of this online form, a confirmation email will be sent to your nominated email address. If you have any specific queries or concerns, Dr Lancashire would be happy to discuss them with you by phone. Please note: items marked * indicate mandatory fields. GP/Specialist details Referring Doctor Name * Referring Doctor Practice Name Referring Doctor Provider # * Referring Doctor Address Referring Doctor Suburb Referring Doctor State ACTNSWNTQLDSATASVICWA Referring Doctor Postcode Referring Doctor phone * Please enter phone number with area code included. No spaces please. eg. 0298765432 Referring Doctor email * Patient details Patient First name * Patient Last name * Patient Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Patient phone * Please enter phone number with area code included. No spaces please. eg. 0298765432 Patient clinical condition / details * Document uploadsProvide up to five relevant documents (scanned referral, certificates etc). Add a new file Upload Files must be less than 2 MB.Allowed file types: gif jpg jpeg png txt rtf pdf doc docx. Preview