FORMS | medilens

PHARMACY CONSULTING REFERRAL

Submit a referral for independent pharmacy review

Use this secure intake form to provide claim details, clinical context, treating contacts, and supporting documentation so MediLens can prepare clear, evidence-based medication recommendations.

Required fields are marked

Attach supporting documents if available

Independent medication advice for defensible decisions

MediLens reviews referral information, medication history, clinical questions, and supporting files before returning practical recommendations.

• Medication assessment or management

• Injury and accepted condition context

• Treating clinician and pharmacy contacts

Referral Form

Please complete as much information as possible. Mandatory fields are marked with an asterisk

1. Reason for Referral

Reason

2. Service Required *

Single Choice

Medication Assessment

Medication Management

Other Service

Unsure

If other, please describe

3. Claimant Details

Claim Number *

First Name

Last Name

Date of Birth

Date of Injury

Description of Injury and Diagnosis

Accepted Conditions / Medication

Declined Conditions / Medication

4. Treating Clinician/ Pharmacist Contact

Clinician Name

Clinic / Practice Name

Clinician Phone

Clinician Email

Pharmacist Detail

Pharmacist Name

Pharmacist Phone

5. Questions and Relevant Information for MediLens Pharmacist

Questions for our pharmacist / relevant information

6. Referrer Details (e.g. insurer details)

Name

Phone

Job Title

Company name

Company Email Address

7. Supporting Documentation

Supporting documents

E.g. medication lists, reports, correspondence, or relevant claim documents

Documentation notes

I declare that the information provided is accurate and complete, and I have authority to submit this referral for review. *

What happens next

MediLens reviews the supplied referral information independently and follows up if additional documents or clarification are required.

Submit referral

Send the required claim, service, and claimant details with any available documentation notes.

Clinical review

A pharmacist reviews the referral, medication context, accepted conditions, and questions raised.

Recommendations

MediLens returns clear, independent recommendations to support safer medication decisions.