New Patient Form (Residential Aged Care or Disability Home)

New Patient Form (Outreach Care)

Thank you for your interest in our primary healthcare service. To help us assess your interest and provide these services we would be grateful if you would complete this form.

Is the resident in a RACF or Housebound *

Residential Aged Care FacilityHouseboundIndependent Living Unit

Are attending this facility as: *

Respite residentPermanent resident

Which Residential Aged Care Home? *

Please note as a respite resident you will be charged a private fee for any consultations with our team members. The fee varies based type, length and time of consultation. However, our the gap that is charged is fixed. The gap fee is currently $65. (If you have provided concession card details this will be discounted by 40%).

Always check our website for upto date details of fees.

Are you completing this for on behalf of somebody else? *

YesNo

Select "yes" if you are completing this form on behalf of somebody else.

Your name? *

Your email *

Your best contact number *

Your relationship with the patient *

Describe relationship *You specified 'other'. Please describe the relationship.

Do you hold the Enduring Power of Attorney?

Do you hold Guardianship?

EPOA Documentation

Browse

Please attach the EPOA documentation if possible

Guardianship documentation

Browse

Please upload the guardianship documentation

Patient details

Title *

First Name *

Last Name *

Gender *

Date of birth *

Do you identify as *

Address *Enter the address of the patient. If moving into a facility please enter the address of the facility

Email Address

Contact phone number

Facility name? *If being admitted to a residential aged care facility then please enter the name of the facility.

Date you are moving into the facility (or moved in) *

Select which of the following you have? *Please select all options that are correct.

Medicare Number *

Expiry date *

DVA number *

Type of DVA card *

Concession card number *

Expiry date (Concession card) *

Private Insurance Provider *

Policy number *

You have selected none. Our services in this case will be privately charged. Full details of our private fees is available on our website.

Confirmation *

I understand that private fees will be charged in absence of Medicare or DVA card

You have NOT PROVIDED concession card details.. Our services in this case may incur a gap fee. Full details of our private fees is available on our website.

Confirmation Concession card *

I understand that a higher gap fee may be charged in absence of a concession card.

Emergency and Next of Kin contact details

Emergency contact

Name *Please enter the full name of the emergency contact

Relationship *Please enter the relationship of the emergency contact to the patient

Contact number *Please enter the best contact number for the emergency contact

EmailPlease enter the email of the emergency contact

Next of kin

Name *Please enter the full name of the next of kin

Relationship *Please enter the relationship of the next of kin to the patient

Contact number *Please enter the best contact number for the next of kin.

EmailPlease enter the email for the next of kin.

Previous GP details

Please tell us the details of the previous GP so we can request and obtain the medical records or a health summary from them.

Name of previous GP *Please enter the name of the previous GP

Address of previous GP *Please enter the name of the previous GP.

Telephone *Please enter the phone number of the previous GP

FaxPlease enter the fax number for the previous GP

Next Practice Deakin and Prestantia Health are related organisations. Some of our doctors provide services through Next Practice and others through Prestantia Health. Next Practice Deakin provides the administrative support to Prestantia Health.

How did you hear about Next Practice Deakin?

Please specify which other source?

Consent

Consent *

I consent to Next Practice Deakin/Prestantia Health providing ongoing care and to the release of medical records from the previous GP to Prestantia Health/Next Practice Deakin.I understand that clinical records are shared between the GP and residential aged care facility/disability home in order to provide optimal and safe care. I consent to sharing of records between the GP and the facility.I understand that for medical services to residents in aged care are bulk billed and these are processed electronically. I give my consent to this. (Where a service does not attract a Medicare rebate then I will be approached to give consent prior to providing the service)I understand that to deliver optimal care a comprehensive medical assessment and contributions to care planning is undertaken and I consent to these servicesI agree to be contacted by SMS and/or email in relation to services provided by Next Practice or for communication about my care.Next Practice Deakin undertakes quality improvement and research for improved evidence-based care. I consent to Next Practice Deakin using and sharing my de-identified and anonymised data for quality improvement and research purposes under standard data protection and ethical requirements.

I agree to pay the fees as outlined above for respite residents. I will inform Next Practice Deakin if the residency status changes to permanent. *

I consent to Next Practice Deakin/Prestantia Health providing ongoing care and to the release of medical records from the previous GP to Prestantia Health/Next Practice Deakin. *

I consent to voluntary registration under MyMedicare. For more information hover over the word consent. (If you are a respite resident this will only be processed at the time you become a permanent resident).

You have opted to not register under MyMedicare. There is an annual fee of $500 payable in quartely amounts of $125.00 for patients who are not registered under MyMedicare with Next Practice Deakin residing in residential aged care. You will be asked to complete a regular payment authorisation. By signing this form you confirm you agreement to pay this fee.

Select the option that applies *

Signature *

Clear

Please sign the form.

Name *

Date of signature *Enter today’s date