DVA Referral Form

Department of Veteran Affairs and Military Personal Services

Exercise Physiology Referral Form

If your patient is covered under DVA or Military Personal Services, we are able to provide
Exercise Physiology to help them with both physical and mental health.

"*" indicates required fields

Referral Type*

Department of Veteran Affairs

Military Personal Services

Patient Name*

Patient First Name Patient Surname

Patient Date of Birth*

Diagnosis*

Requred Treatment and Additional Information

Practitioner Name*

Title*

Practitioner Email*

Practitioner Phone*

Practitioner Address

Street Address City State / Province / Region ZIP / Postal Code Country

Contact

29 Advantage Road
Highett VIC 3190

03 8290 0248 / 1300 863 347

admin@medhp.com.au

Gym Access Hours

7 days a week
6am – 10pm

Please note that MEDHP will be closed from Wednesday 25^th December to 5^th Jan, and will reopen on Monday 6^th Jan 2025.

We acknowledge the Traditional Owners of the land where we work and live, and pay our respects to Elders past and present. We celebrate the stories, culture and traditions of Aboriginal and Torres Strait Islander Elders of all communities who also work and live on this land.