International Patient Referral Request

This form must be completed for all international patients referred to the Royal Children’s Hospital (RCH), Melbourne, Australia, for medical treatment or consultation. Your child’s doctor or medical specialist must complete this referral request form.

An acknowledgement of receipt will be sent by email to the guardian and referring doctor nominated on this form.

* = required field.

Patient details

Patient first name

Patient last name

Patient gender

Patient date of birth

Patient country

Has the patient previously seen a doctor or had a test at RCH?

Yes

Medical Record Number

Guardian Name

Relationship

Guardian Phone Number

Medical Treatment Visa
(Subclass 602)

All international patients travelling to Australia for medical treatment will be required to obtain a Medical Treatment Visa (Subclass 602). To be eligible to obtain a Medical Treatment Visa (Subclass 602) evidence must be provided that arrangements have been made to pay the full cost of treatment.

Payment Method:

Self-pay

Insurance coverage

Third party payer

Embassy

Brief Medical History

characters remaining.

Notes

Copies of all pathology, laboratory or diagnostic imaging reports should be emailed to: RCHGlobal.Enquiries@rch.org.au

Echocardiograms must be sent on CD/DVD (Dicom format) to:

RCH Global
Level 4 West, Corporate Offices
The Royal Children's Hospital
50 Flemington Road
Parkville, Victoria 3052
Australia

How did you hear about us?

Where did you hear about us?

Referring doctor details

Referring doctor name

Referring doctor email

Referring doctor telephone

All international patient referrals will be considered by RCH Global and a medical specialist in line with our eligibility requirements and capacity. Completion of this patient referral request form does not guarantee treatment or consultation at RCHM.

The Royal Children's Hospital Melbourne

RCH Global

International Patient Referral Request

Notes