Referral Form

Referral Form

A NOTE FROM CHILDREN'S PODIATRY CLINICS

Dear Health Care Professional,

Thank you for your referral to Children's Podiatry Clinics.

At Children's Podiatry Clinics, our focus is on treating each child holistically, ensuring their overall well-being.

We provide care for children of all ages,including newborns, addressing a range of conditions including but not limited to in growing toe nails, flat feet, gait abnormalities, leg pain, developmental issues, motor sensory issues, sensory porcessing disorder and foot-related concerns to ensure their optimal foot health and overall well-being.

We have undertaken additional education and training to provide services to Neurodiverse Children and their families also.

To proceed with making an initial appointment, we kindly ask you to complete the form below and then ask the child's parent/caregiver to contact our clinic at 8645 9845 to schedule an appointment at their earliest convenience.

We look forward to working collaboratively.

Thank you once again for entrusting us with this referral.

Best wishes,

Lauren Osborne and Melissa Biedak

Podiatrists

CHILD'S DETAILS

MasterMissN/A

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

MaleFemaleNon binaryPrefer not to say

CONTACT DETAILS

Home Phone

Mobile Phone *

Address *

City / Suburb *

State *

Postcode *

PARENT/GUARDIAN 1 CONTACT DETAILS

PARENT/GUARDIAN 2 CONTACT DETAILS

Name *

Name

Mobile Phone

Parent 2 Mobile Phone

Email *

Parent 2 Email

REFERRING HEALTH CARE PROFESSIONAL (if applicable)

Referring Doctor’s Name

Address

Family Doctor/ Regular General Practitioner Name (if different to referring doctor)

Address

Does the child take any medications? If yes, which medications?

Please upload relevant reports

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If you use Alias please write the Alias name & surname

EPC/NDIS Plan

Do you have an EPC or NDIS Plan?

YesNo

Plan Type

EPCNDIS Plan

NDIS Plan Number

NDIS Plan Dates(mm/yyyy)

NDIS Plan Manager(mm/yyyy)

Referring GP Name and Address

Please upload EPC/NDIS Plans

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REASON FOR REFERRAL:

Describe the child's current challenges *

Does the child have any diagnosis? *

OTHER INFORMATION

Please provide any other information you believe is important for our first consult

Name of Person Referring to our service *

Best contact detail for person referring to our service (email address/phone number) *

Date

Name of Parent or Guardian who gives consent

PERSONAL AND HEALTH INFORMATION COLLECTION STATEMENT

Children’s Podiatry Clinics is an independent practice under the ownership of Melissa BIedak. You may contact Children’s Podiatry Clinics by writing to Children’s Podiatry Clinics, 189 Somerville Road Yarraville 3013 by emailing hello@childrenspodiatry.com.au or by calling Melissa Biedak on 03 8645 9845. You have the right to gain access to the information held by Children’s Podiatry Clinics about you. Our Privacy Policy (available upon request) contains information on how you may request access to, and correction of, your personal information and how you may complain about a breach of your privacy and how we will deal with such a complaint.

Collection of Client information disclosure of client information:

Children’s Podiatry Clinics needs to collect information about you and your child for the primary purpose of providing quality treatment.

In order to fully assess and treat you and your child, we need to collect some personal information from you.

This information will also be used for the administrative purposes of running the practice such as billing you or through an insurer or compensation agency.

Information will be used within the practice for handover if another practitioner provides you with assistance.

Client information is stored securely and only practice staff has access to it.

Children’s Podiatry Clinics takes all reasonable steps to ensure that information collected about you and your child is accurate, complete and up-to-date

You may have access to your information on request and if you believe that any of the information is inaccurate, we may be able to amend it accordingly.

Children’s Podiatry Clinics may disclose information regarding assessments or treatment to your Doctor or other health providers only with your consent.

In the case of insurance claims, it may be necessary to disclose information and/or collect information that affects your treatment.

Children’s Podiatry Clinics will not disclose your information to commercial companies, however specific services or product information as supposed suitable for your management, may be forwarded to you by us, unless you instruct Children’s Podiatry Clinics not to forward this type of information.

Your written consent will be obtained at the start of your treatment in order to carry out the above activities. We do not disclose your personal information to overseas recipients.

If you do not provide relevant personal or health information, in part or in full, to Children’s Podiatry Clinics it may result in incomplete assessment. This may impact the following therapy that is provided.

Any concerns that you may have about this statement or about your management can be directed to Melissa Biedak, 189 Somerville Road, Yarraville 3013

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