Fertility Referral

Dear QFG Please see reverse for a full list of QFG Specialists and their locations.	Date

Thank you for seeing:

Patient name

Patient address

Date of birth            Phone number  Patient email (if possible)

Partner name		Partner date of birth	

Please review my patient for: (please tick)

Fertility assessment		Fertility treatment		Ovulation Tracking				
						
Ovarian reserve testing		Semen analysis		Recurrent miscarriage				
						
Intrauterine insemination (IUI)		Ovulation induction		In vitro fertilisation (IVF)				
						
Ovarian tissue freezing		Egg freezing		Sperm freezing				
						
Egg donation		Sperm donation		Surrogacy				
Other:									

Medical History:

REMINDER:

Please ask your patient to bring all relevant medical reports and scans to their appointment.

Your patient will be contacted by our patient liaison officer to make an appointment.

Referring Doctor:

Name

Address

Phone			Provider No.			
						
				QFG103 10.04.2024	
Please email to forms@qfg.com.au ◆	1800 111 483 ◆  qfg.com.au	

Network & collective strength

Spring Hill 203 Wharf Street	Spring Hill 71 Bradley Street	Everton Park 4/137 Flocton Street	

Dr David Molloy	Dr Shane Higgins	Dr Warrick Smith	Dr Melissa Luckensmeyer 3839 1033	Dr Ee Min Kho		
				3353 6855		
3015 3130	3015 3140	3832 0247				
			Spring Hill 201 Wickham Tce			

Dr Kellie Tathem	Dr Julie Buchanan	Dr Albert Jung								Dr Eva Kretowicz	Dr Terry Sheahan		
					Dr Eva Kretowicz 3831 4090	3831 4090	3353 3100		
3015 3180	3015 3180	3015 3155											

													
										Spring Hill 225 Wickham Terrace		
Spring Hill 225 Wickham Terrace			South Brisbane							
								Metabolic Physician,		
			2/40 Annerley Road							
										Clinical Geneticist & Paediatrician		

													

Dr Scott Salisbury	Prof Hayden Homer			Dr Alex Alexander		Prof David Coman 3832 9876		
3010 2121	3832 2263	3891 9333				

Gold Coast & Ballina Clinic		Gold Coast Pindara Place, 13 Carrara Street, Benowa		

Dr Michael Flynn	Dr Penelope Isherwood	Dr Andrew Cary	Dr Catherine Mills	Dr Gary Swift	Dr Abigail Evans	
5564 8011	5597 2660	5597 3770	5597 5023	5564 6017	5564 9683	

Sunshine Coast Kawana Private Hospital, Birtinya

Gympie Specialist	Hervey Bay Consulting	
Centre 71 Channon St	Suites St Stevens Hopsital	

Dr Petra Ladwig 5437 7244	Dr Dana Moisuc 5478 3533	

Cairns 16 Upward Street

Mackay 5 Discovery Lane, North Mackay

Dr Naguesh Gaunekar	Dr Ritu Rana	Dr Sally Rodrigues	
4942 1199	4965 6565	4942 1199	

Toowoomba		Townsville Oxford Medical Suites	
9 Scott Street		18 Oxford St, Hyde Park	

Dr Anne Coffey 4041 2400	Dr Ruth Hodgson 4041 2400	Dr Rachel Collings	Dr Ron Chang	Dr Vanessa Lusink		
		4638 5533	4772 8900	4772 8900		

SPECIALTY AREAS KEY:				
Fertility Specialist	METRO CLINICS			
Gynaecologist				
				
Obstetrician	REGIONAL CLINICS	qfg.com.au ◆  1800 111 483