Full name of patient (first name, middle name, family name) (required) Date of birth of patient Name of Mother Name of Father Address Suburb State Postcode Contact email (required) Contact phone number Please explain your concerns, describing what happened to your child, and any reactions you have seen, including how long it took for the symptoms to appear. Please provide as much detail as possible in order to allow proper consideration of the urgency of the appointment. The more information you provide, the better. What are other concerns you have about the patient’s health? Has the patient had allergy tests before? If yes, please email a copy of the results to humpty@paediatrix.com.au YesNo Has the patient had blood tests before? If yes, please email a copy of the results to humpty@paediatrix.com.au YesNo What triggers have set off the problem? Please list: Food Environmental Other Is the patient eating a restricted diet or avoiding any particular foods? Please detail the restrictions. If you have any documents/files/photos you want to send us, please email them to humpty@paediatrix.com.au Please remember to bring in your child’s medical records book (“Blue Book”), and all previous records of weight and height measurements. You will receive an automated email in response to the successful receipt of your request for an appointment. *Ps, if you do not hear from us within three business days please follow up with a phone call (02 9634 8600) or email humpty@paediatrix.com.au in case of technical difficulties.
