Hazel • Apply to become a trusted In-Person Referral Partner

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Select you specialty
‍Multiple selection allowed

If you chose other, can you please specify?

Please list all qualifications relevant to your specialty

Current practice or clinic details

What services can you provide to the Hazel patient community?

What is the cost of this service?

Are patients able to claim a medicare rebate for virtual consultations with your specialty? If yes, please indicate rebate amount or item code

What is the approximate wait time for an appointment currently?

Why do you think you are an ideal Hazel Referral Partner?

How did you hear about Hazel?

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