Send Enquiry

To send an enquiry, please complete the online form below. One of our friendly Receptionists will be in touch shortly.

For urgent enquiries please call us on 07 3239 5000.

Personal Information
First Name*
Last Name*
Date of birth*
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Details about your condition*
Referral Information
Do you have a current referral from your GP or Optometrist?*
- Yes
- No
GP, Ophthalmologist or Optometrist Name
Practice Name
Referrer's Phone Number
Which QEI Specialist are you being referred to?
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Have you been treated at the QEI Clinic before?
- Yes
- No
Specific appointment request information
Contact Information
Home phone
Mobile
Email address*
How would you prefer to be contacted?
- Email
- Phone