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Referral for Treatment

Please submit the form below to complete your referral.

You can also download our referral form here. Email your referral to reception@tsm.com.au

Referral for Treatment
Referring Practitioner’s Details

Upon submission, we will email you a copy of your referral.

Referral Type

Specialist Sports Physician

Physiotherapist

Preferred Practitioner (if Applicable)

Date:

Patient’s Name:

Patient Phone:

Date of Birth

Reason for Referral

Investigations (Imaging Centre)

Referring Practitioner’s Name

Practice Name

Practice Address

Referring Practitioner’s Telephone

Referring Practitioner’s Fax

Referring Practitioner’s Provider Number:

Signature field

I agree to have my details saved

Email address

Addresses

9/8 Parap Place
Parap, Northern Territory

PO Box 740 Parap
Northern Territory 0804

Contact

reception@tsm.com.au

Hours of Operation

Monday – Thursday: 7:30am – 7:00pm
Friday: 7:30am - 5:00pm
Saturday: 8:00am – 1:00pm

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