NPD Private Forms

Private Services

The following is for payment and request of private administration services at Next Practice Deakin.

Select the service(s)

Referral ($27)Prescription ($19)Objection claim that an elector should not be enrolled ($19.50)Confirmation of lack of capacity to support enactment of EPOA ($25.00)Certificate of Life ($25.00)

All fees include the clinician's fee and a $2.00 administrative services fee.

Capacity for decision-making refers to the ability of an individual to understand, evaluate, and communicate choices regarding personal, financial, legal, and medical matters. It is a complex area and for further information please refer to the information on our website. To help understand the reason you require this letter please provide further details below. When your request is received it will be reviewed by our clinician and further information may be required and a capacity assessment before the lack of capacity can be confirmed. We will keep you updated and advise you if this is the case.

To help us assess this request, please describe the decision(s) that need to be made and the current situation that has led to this request to activate the Enduring Power of Attorney. *Please include: The type of decision(s) being considered (e.g. health care, living arrangements, financial matters) Why the decision(s) need to be made now Any concerns about the person's current ability to understand, make, or communicate these decisions Any recent changes in the person’s health or behaviour relevant to this request

Total Amount

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient's address of residence *

Usual GP *

Are you acting on behalf of the patient?

I confirm that I have the authority to act on behalf of the patient named above and that I hold Enduring Power of Attorney. *

Your first name *

Your last name *

Your Email Address *

All prescriptions will be sent as e-Prescription

Your request will be passed onto your usual clinician. The clinician will review the request and issue the prescription if clinically appropriate or safe to do so. On reviewing your file it is possible the clinician may request an appointment for further assessment. In this eventuality, the fee for the prescription item will be credited when you attend for your consultation.

The fee is for upto a maximum of three prescriptions.

Script delivery *

SMSEmail

Phone numer for SMS for eToken *

Email for e-prescription token *

Name of medication *Enter the name of the medication

Type *Enter type of medication - tablet capsule etc

Strength *Enter the strength of the tablet you take e.g. 50mg

Dose taken *Enter the dose you take e.g. twice a day

Name of medicationEnter the name of the medication

TypeEnter type of medication - tablet capsule etc

StrengthEnter the strength of the tablet you take e.g. 50mg

Dose takenEnter the dose you take e.g. twice a day

Name of medicationEnter the name of the medication

TypeEnter type of medication - tablet capsule etc

StrengthEnter the strength of the tablet you take e.g. 50mg

Dose takenEnter the dose you take e.g. twice a day

Is this a new referral or ongoing referral? *

New referralOngoing referral

For all new referrals we recommend you make an appointment.

Name of specialist to whom the referral is for? *

Address of specialist

Street address

City

State

Postcode

If a person is unable to vote because they are no longer capable of understanding the nature and significance of enrolment and voting (e.g. because of dementia) then their name may be removed from the electoral roll. To do this requires the completion of a form known as:

Objection claim that an elector should not be enrolled

Once you have completed the form you can upload it using this form for completion by their usual medical practitioner. This service does NOT have an associated Medicare rebate and therefore is a private service (Cost $17.50).

Once the payment has been cleared the Doctor will complete the form and we will arrange to return it to you by email or you can choose to collect it from our practice in Deakin.

Objection Form *

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Please email me the completed formI will collect the form from Next Practice Deakin, 2/4 Makin Place, Deakin (Opening Hours M-F: 8:00 - 18:00)

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