Referral Form

Practitioners may use the referral form below. We also accept referrals via Medical Objects.


Referral Form to Dr Sami Ahmad

Specialist Pain Medicine Physician


All fields marked * are required.

  • Patient Details

  • Referring Doctor Details:

  • Referrer’s Signature:


  • This field is for validation purposes and should be left unchanged.




TREATMENT DISCLAIMER It is important to understand that whilst our therapies can help alleviate symptoms in many patients and slow or even reverse degenerative processes, at times it does not work for all patients. Consequently, Brisbane Regeneration can neither predict nor guarantee success for individual patients. Based on additional information, patient's current health situation and/or unforeseen health risks, the medical staff can always, in the interest of the individual patient, propose another kind of treatment.