Refer a patient

Complete the form below and Penny will confirm receipt within one business day. Nothing will happen without your knowledge — all clinical issues are escalated to you, or handled within pre-agreed parameters.

Not ready to refer yet? Use the prescriber enquiry form to request a callback. Prefer to email directly? Use the plain-text template at the bottom of this page.

How this form works — and how it protects patient information

When you submit, your referral is emailed directly to Penny. No copy of the submission is kept in this website’s database. Any files you attach are sent with that email and then removed from the server automatically. If you would rather nothing pass through this website at all, use the email-directly option below — that sends straight from your own email system.

Referral form

Your details

Your name (required)

Your role (required)

Best contact for this referral (required)

Practice or clinic

Patient details

Patient name (required)

Patient date of birth (required)

Patient phone or contact (required)

Carer or guardian

Access or communication considerations

What I'm referring for

Tick all that apply. Not sure which fits? Describe it in the goal field below.

Targeted medication educationShared decision-making sessionLegacy Review (Legacy Report and Medication Portrait)MDT or joint sessionSystems and supply navigationConcierge — add to any serviceNot sure — described in context below

Goal of this referral

(required) — one sentence is enough

How involved do you want to be?

Attach recent letters (optional)

Recent letters or specialist reports — PDF, Word or image, up to 10MB each. Over 10MB or a large volume of records? Use the email-directly option below the form instead.

Attachment 1

Attachment 2

Attachment 3

Anything else (optional)

Prefer to email directly?

Copy the template below into an email to refer@maxwellminds.com.au. Attach your own files in your own email client — nothing passes through this website.

Subject: Patient referral — [patient name]

Referring clinician: [name · role · practice · best contact]

Patient: [name · DOB · phone]
Carer or guardian: [if applicable]

Referral goal: [one sentence — what you need and why]

Service requested:
  [ ] Targeted medication education
  [ ] Shared decision-making session
  [ ] Legacy Review (Legacy Report + Medication Portrait)
  [ ] MDT or joint session
  [ ] Systems and supply navigation
  [ ] Concierge — add to above
  [ ] Not sure — see context below

My involvement:
  [ ] Hands-off — report back when done
  [ ] Keep me in the loop at key points
  [ ] Closely involved throughout

Clinical context:
[2–3 sentences Penny should know before contacting the patient]

I will send separately: medical summary · current medication list · recent letters

— [Your name]

Open my email app to refer@maxwellminds.com.au