Request for Appointment with Dr NJ Arachchi

The Pentlowe Health is a specialist medical practice. You would need a referral letter from your local GP or another doctor to make an appointment.

Do you have a referral letter? *

Yes No

Please discuss your medical concern with your GP and obtain a referral as appropriate .

Thank you

Pentlowe Health

First Name *

Last Name *

Email Address

Best contact number *

What is the reason for your appointment *

Have you visited us before

YesNo

Comments

We prefer to obtain your referral letter before your appointment. This allows us to allocate apppriate time for the appointment and obtain further information prior to your review with us. You could upload your referral letter here. If you are concerned about your privacy and confidentilaity please read our privacy and confidentiliaty page at www. pentlowehealth.com.au.

If you do not want to upload your referral letter/s please let us know your referring doctor's name, clinic and contact details. Our admin staff will call to obtain these information via fax.

I agree to upload my referral letter and other information *

YesNo

Referral letter - Front page

Browse

You could attached a PDF document or take a photo from your phone camera and attach.

Page 2 upload

Browse

Please attach additional pages

Page 3 upload

Browse

Page 4 upload

Browse

Page 5 upload

Browse

Would you consent for us to obtain relevant medical information (including your previous investigation results) from your referring doctor and other medical providers? *

YesNo

Name of your referring Doctor

Your referring doctor contact phone number

Your referring Doctors clinic Name and address

Please tick this before submitting *

Save and Complete Later