Online Referral Form

If you or someone you know has been diagnosed with cancer, Solaris Cancer Care is here to support you.

Please fill in the referral form below and one of our support centres will be in contact to see how we can support you or your loved one.

Online Referral Form

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This field is for validation purposes and should be left unchanged.

Referrer Details

Name

Phone

Referring service

Town / region

Referral Date

Client Details

Name

Title First Last

Date of birth

Pronouns

Phone

Residential address

Street Address Address Line 2 City State Postcode

Preferred contact method

Phone

SMS/Text

Aboriginal and/ or Torres Strait Islander?

Yes

Prefer not to say

Interpreter required?

Yes

Language

Interpreter phone

Interpreter name

First Last

Emergency contact name

Title First Last

Emergency contact email

Emergency contact phone

Reason for Referral

Reason for rerral

Cancer diagnosis / type

Current treatment / stage

Key concerns / support needs

Requested supports

Please attach any supporting documents here

e.g. summary / letter, treatment plan, discharge summary

Drop files here or

Accepted file types: pdf, doc, docx, jpg, gif, png, tif, Max. file size: 8 MB, Max. files: 10.

We need to collect personal information to process this referral, communicate with you and conduct normal business. By providing your personal information, you agree that your information will be used and disclosed by Solaris Cancer Care in accordance with our Privacy Policy.

Get support

Online Referral Form