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

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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 *SpouseNext of KinSonDaughterNephewNieceGrandchildOther

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

Do you hold the Enduring Power of Attorney?

Do you hold Guardianship?

EPOA Documentation

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Please attach the EPOA documentation if possible

Guardianship documentation

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Please upload the guardianship documentation

Patient details

Title *MrMrsMissMs

First Name *

Last Name *

Gender *MaleFemaleOther

Date of birth *

Do you identify as *AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNeither Aboriginal nor Torres Strait Islander

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? *

Medicare cardDVA cardConcession cardPrivate health insuranceNone of the above

Please select all options that are correct.

Medicare Number *

Expiry date *

DVA number *

Type of DVA card *GoldWhiteOrange

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?Recommendation from family/sourceRecommendation from another healthcare providerRecommendation from a facility or home care providerRecommendation from hospitalSocial mediaWebsiteOther

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 servicesNext 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 consent to voluntary registration under MyMedicare. For more information hover over the word consent.

×  

By signing this form I agree to the following:

• I understand that registering in MyMedicare is voluntary.

• I consider this Practice to be my regular primary health care provider.

• I understand that I can only be registered with one Practice at a time. By submitting this form, any existing registration in MyMedicare will be withdrawn, and my previous Practice and provider will automatically be notified that I am no longer registered with them under MyMedicare.

• I understand that I will remain registered unless:

  • I register with a different Practice.

  • I request my GP/Practice or Services Australia to withdraw my registration.

  • My GP or Practice decides to withdraw my registration.

• I understand that there is no cost to register in MyMedicare.

• I declare I have read and understand the MyMedicare Privacy Notice and consent to my personal information being collected, used and disclosed by the relevant agencies such as Services Australia, the Department of Health and Aged Care, the Australian Digital Health Agency and, where applicable, the Department of Veterans’ Affairs as specified in the MyMedicare Privacy Notice (a link to this notice is provided in the Privacy Statement at the bottom of this form).

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Select the option that applies *I am the patient.I am the patient’s representative and confirm that I hold authority to legally act on behalf of the above named patient.

Signature *

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Please sign the form.

Name *

Date of signature *Enter today’s date

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