GP and Other Clinicians Referral Form – Geelong Long Covid Clinic

GP and Other Clinicians Referral Form

Patient Details

Card Details

Clinical Information

Current Medications

Do you have any current medications?

Yes No

If YES, please list your current medications, including vitamins

Social History

Medical History

Please attach any Investigations / Test results / relevant plans relating to long COVID symptoms

Emergencies

In case of emergency, please dial 000

For After Hours Care

Please call 137425

Site Map

Operating Hours

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