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Referral form for      ¬ ovulation tracking     Information for referrers
Step 1
The referral form below is to be completed and signed by the referrer.
Upon completion, we request that either the referrer or the patient email the referral form
to ovulationtracking@genea.com.au or fax it to 1300 386 306.

Step 2
When the patient is ready to start, they should call our ovulation tracking coordinators at 1300 117 698 
on days 1 to 3 of their period. Full instructions on the next steps will be provided to the patient at this time.

Step 3
The patient will progress through the ovulation tracking process before a summary of results is provided 
to the referrer at the end of the three cycles or earlier if pregnancy occurs. 
Genea offers three tracking cycles to ensure the best possible chance of success.

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Further information about the service can be found on our website at genea.com.au.            
*All mandatory fields must be completed.   
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Referral for ovulation tracking and/or fertility assessment
Three cycles at no out-of-pocket* cost

Patient details
*Patient’s given name:   [ Given name ]      *Patient’s surname:   [ Surname ]         *Kindly provide the patient’s name exactly as it appears on their Medicare card
*Date of birth:   __/__/____             
*Medicare number:   [ _________ ]        *Medicare reference number:    [ __ ] 
*Home address:   [ Address ] 
*Email address::   [ Email Address ] 
*Mobile number:   [ Mobile number ] 
Regarding partner
Partner’s name (if applicable):
Partner’s mobile number:
Refer to
(Preferred Genea Fertility Specialist):
Requesting referrer details
*Requesting referrer’s name, address and provider number:
Ovulation tracking cycle summary reports are sent to the referring doctor via email only.  Please provide your email address:

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I understand that if my patient does not achieve a positive pregnancy result after three cycles, they are offered further investigation through a consultation 
with a Genea Fertility Specialist. If a preferred Fertility Specialist is not requested above, one will be chosen in consultation with the patient. 

*Referring doctor’s signature
Date: :   __/__/____  

*	Please note, the no out-of-pocket service is only guaranteed at a Genea pathology collection centre. You are free to choose your own pathology provider. Should the patient present to have their blood tests at another provider, 
the patient may be out-of-pocket for those tests. Genea has legal obligations to protect your personal information and to provide you with details about how we deal with this information.
	Please read our Privacy Policy and Collection Statement at  genea.com.au/policies

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Genea Fertility Specialists
Please choose one of the following Fertility Specialists accredited by Genea. For further information on these doctors,  please visit our website genea.com.au
NEW SOUTH WALES 	
	
Sydney CBD 	
	
Dr Ying Li				1300 323 297
Dr Mark Livingstone 		(02) 9231 4513
Dr Derek Lok 			(02) 8734 3395
Dr Anthony Marren 		1300 330 990
Dr Danielle Robson 		1300 330 279
Dr David Shelley-Jones 	(02) 9221 2904
Dr I-Ferne Tan			(02) 8919 8000
Dr Simon Nothman 		(02) 8357 1747
	
Bella Vista 	
	
Dr Monique Atkinson		(02) 9037 6333
Dr Peter Bell 			(02) 9894 0040
Dr James Brown			(02) 8919 8000
Dr Arifa Khan 			(02) 9480 8746
Dr Derek Lok 			(02) 8734 3395
		
Bondi Junction 	
	
Dr Simon Nothman 		(02) 8357 1747
	
Glebe 	
	
Dr Ying Li				1300 323 297
Dr Becky Taylor 			(02) 9128 2052
	
Gosford 	
	
Dr Myvanwy Mclveen 		(02) 4908 6555
Dr Peta Skillbeck 			(02) 4321 0500
	
Liverpool 	
	
Dr Tim Chang 			(02) 4628 5292
Dr Quang Ho 			(02) 9796 2099
Dr Sonal Karia 			(02) 8734 3333
Dr Derek Lok 			(02) 8734 3395
	
Manly 	
	
Dr Danielle Robson 		1300 330 279
		
Miranda	
	
Dr Sonya Jessup 			(02) 9157 8599
	
Newcastle 	
	
Dr Angela Dunford 		(02) 4908 6555
Dr Erin Fuller			(02) 4908 6555
Dr Matthew Holland 		(02) 4952 7409
Dr Myvanwy McIlveen 		(02) 4908 6555
	
Orange 	
	
Dr Miguel Marquez 		(02) 6361 3654
Dr Andrew Wong 			(02) 6361 3654
	
St Leonards	
	
Dr Anthony Marren 		1300 330 990
	
Wollongong 	
	
A/Prof Lionel Reyfttman 	(02) 4227 6589
Dr Vanessa Tatham		(02) 4242 9000
	
AUSTRALIAN CAPITAL TERRITORY	
	
Canberra 	
	
Dr Felicity Brims			(02) 6282 7700
Dr Tween Low 			(02) 6162 1649
Prof Steve Robson 		(02) 6282 3033
Dr Sumi Saha 			(02) 6113 9080
	
VICTORIA	
	
Heidelberg 	
	
Dr Kate McIlwaine 		(03) 9977 7740
Dr Toby Angstmann 		(03) 9101 7055
Dr Samantha Mooney 		1300 671 350
	
Genea Melbourne City - East Melbourne 	
	
Dr Alice Huang 			(03) 9417 1088
Dr Chandrika Parmar 		(03) 9101 7070
A/Prof Alex Polyakov 		(03) 9486 0677
Dr Genia Rozen 			(03) 8376 6230
	
Genea Melbourne City - North Melbourne 	
	
Dr Catarina Ang 			(03) 9500 1828
Dr Toby Angstmann 		(03) 9101 7055
	
WESTERN AUSTRALIA 	
	
Perth 	
	
Dr Michael Allen 			(08) 9389 4200
Dr Julia Barton 			(08) 9389 4200
Dr Sean Copson 			(08) 9389 4200
Dr Alexandra Cottam 		(08) 9389 4200
Dr Gregg Eloundou 		(08) 9389 4200
Dr Mathias Epee 			(08) 9389 4200
Dr Richard Murphy 		(08) 9389 4200
Dr Joo Teoh 			(08) 9389 4200
	
Mandurah 	
	
Dr Gregg Eloundou 		(08) 9389 4200
	
SOUTH AUSTRALIA 	
	
Adelaide	
	
Dr Kate Gowling 			(08) 8100 2900
Dr Alex Hubczenko 		(08) 8100 2900
Dr Victoria Nisenblat 		(08) 8100 2900
Dr Bruno Radesic 			(08) 8100 2900
Dr Jodie Semmler 		(08) 8100 2900
Dr Michelle Wellman 		(08) 8100 2900
	
QUEENSLAND 	
	
Brisbane 	
	
Dr John Esler 			(07) 3613 3900
Dr Lisa Harris			(07) 3301 0100