External Long Term Follow-up Program referral form

This resource has been developed by PICS, Victoria’s Paediatric Integrated Cancer Service. 

The form below is for referring childhood cancer patients to the PICS Long Term Follow-up Program (LTFP).

This form is for referrals by healthcare providers external to primary treating centres, such as a general practitioner (GP).

Referrals happen internally at The Royal Children’s Hospital, and a separate form is available for referrals by Monash Children’s Hospital staff.

The form is available in both PDF and Word formats.

Please contact us if you experience any issues downloading resources, or if you are interested in adapting or translating PICS resources or publications.