MCH 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 Monash Children’s Hospital (MCH) staff only.

Referrals happen internally at The Royal Children’s Hospital, and a separate form is available for external referrals by other healthcare providers, such as a general practitioner (GP).

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.