SARA referral form

This electronic form will allow you to refer a patient directly to the SARA program.
We will email you a copy of your submission. Please ensure your email address is correct.

Referring doctor

	Next available doctor		

	Dr Rohit Joshi		
	
Dr Vineet Kwatra

Dr Harminder Takhar

Referring clinician

 Title:

	 Provider number:
	
 Referrer’s first name:

	 Referrer’s last name:
	
 Referrer’s email:

	 Referrer’s phone:
	
 Referring clinic or hospital:

		

Patient information

Patient’s first name:

	Patient’s last name:

Patient’s phone:

	Patient’s email:		
Patient’s date of birth:	Patient’s gender:

		
Patient’s address:

	City:	Postcode:	
State/territory:	Country:

		

Patient referral type

	 Public patient		

	 Private patient		

Medical notes

Smoking history:

	Never smoked		
	
Ex-smoker
		
	Smoker		

Asymptomatic:

Incidental findings

Screen detected
		
Symptomatic:

Reason for referral:

			
Clinical notes / other clinical history

			

Please attach CT Chest results. 

You acknowledge we will use the information you are providing to contact you about your referral request. 
Refer to our Privacy Policy for more information about how we handle personal information.

 Signature:

	 Date:		

Referral Management

Fax:        (08) 8228 6797
Email:    sara@genesiscare.com