Make a Practitioner Referral

Use this short form to provide the client’s contact details, a brief reason for referral and the supporting documents needed for assessment. Please provide only information relevant to the referral.

Client contact: provide at least one client contact method — phone number or email address.

Privacy notice: Healthsmart Exercise Physiology collects the information and documents submitted through this form to assess and respond to the referral and to create or update the client’s clinical record in Cliniko. Submissions are received by authorised staff via email and relevant information is transferred to Cliniko. Temporary website upload files are removed after email processing. Please ensure the client is aware of the referral and that you are authorised to provide their information. Read our Privacy Policy.

Thank you. Your referral has been submitted successfully. Healthsmart Exercise Physiology has received it. Please do not submit it again. We will contact you if more information is required.

Your referral could not be submitted. Please check the form and try again. If the problem continues, call Healthsmart Exercise Physiology.

Referrer Details

Referrer Full Name *

Organisation / Practice *

Referrer Phone *

Referrer Email *

Client Details

Client Full Name *

Date of Birth *

Client Phone Number

Client Email Address

Contact requirement: Provide at least one client contact method — phone number or email address. The form cannot be submitted without one.

Referral Information

Funding Source *

Brief Reason for Referral *

Supporting Documents and Confirmations

Supporting Documents *

Click or drag files here to upload.

Choose File

Upload one to three relevant PDF, JPG or PNG documents. The combined upload limit is 10 MB. Please include only information necessary for this referral.

Required Declaration *

I confirm the client is aware of this referral, that Healthsmart Exercise Physiology may contact the client about it, and that I am authorised to provide the personal and health information included in this form and its attachments.

Privacy Acknowledgement *

I acknowledge that I have read the Privacy Notice and Privacy Policy.