Apply for Services

Client Details

Title: *
First Name: *
Last Name: *
Date of Birth: *
Gender: *
Address: *
Suburb: *
Postcode: *


Contact Details

Phone (Home):
Phone (Work):
Mobile:
Fax:
Email:
Preferred method of communication:
Is client aware of referral? Yes No
Has client received GDQ services? Yes No
Can we contact the client directly? Yes No
Alternative contact name:
Alternative contact phone:
Pension type:
Interpreter required? Yes No
Specify language:
Eligible for compensation Yes No
Purpose of referral:
Cause of impairment:
 

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Contact Us

Guide Dogs
Freecall 1800 810 122
Guide Dogs Shop
1800 007 460
Head Office
Guide Dogs Queensland
Breeding and Training Centre
1978 Gympie Rd
Bald Hills, Qld, 4036

Email Guide Dogs QLD