Submit an NDIS Inquiry with Platinum Healthcare

Complete the form below and we will contact you shortly.

Let's Get Started...

Who is your care inquiry for?: *

Referrer's Details

Your First Name: *

Your Last Name: *

Your Organisation (If Applicable):

Your Relationship to the Participant:

Contact Information

Your Phone Number: *

Your Email: *

Participant's Details

Participant's First Name: *

Participant's Last Name: *

Participant's Date of Birth: *

Suburb Where Services are Required: *

Participant's NDIS Number: *

NDIS Plan Start Date: *

NDIS Plan End Date: *

Participant's NDIS Plan

Participant's Funding Choice: *

Services to be Provided in Private Care Facility?: *

Yes

Planned Budget Allocation ($):

Participant's Background and Medical History: *

Summary of Required Services:

Other Information You Feel will be Helpful:

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