Patient Referral Form

Patient Details

First Name *

Last Name *

Gender

MaleFemale

Date of Birth *

Knowing your cultural background can help us provide healthcare that meets your individual needs. Are you Aboriginal or Torres Strait Islander origin?

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNone of these

Patient Contact Details

Home Phone

Mobile Phone

Email

Street Address

Postcode

City / Suburb

State

Next of kin

Next of kin - name

Mobile number

Medicare

Do you use a different name on your Medicare card?

YesNo

If you use Alias please write the Alias name & surname

Medicare First Name

Medicare Surname

Medicare Card No. (10 digits)Numbers only no spaces required

Medicare Card IRN (Number in front of your name)This is the single digit number next to your name on the medicare card.

Expiry (MM/YYYY)

DVA Card

Do you have a DVA card?

YesNo

DVA Card Type

GoldWhite

DVA No.

Workers' Compensation

Are you seeking this assessment/treatment due to a workplace injury/illness?

YesNo

If yes, do you have an accepted claim for workers' compensation

YesNo

Depending on your state jurisdiction, you may need approval from your claims agent for telehealth services. Please confirm approval of your service with your claims agent.

Claims Agent

State/territory (jurisdiction you were injured in)

Case Manager

Case Manager Email

Referral Upload

We require a valid referral for specialist appointments. Please upload your referral here.

Supporting Document 1

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Supporting Document 2

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Supporting Document 3

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Contact Information

How Telecare Manages Your Information

For any enquiries please contact us on

Phone: 03 9052 4872

Email: admin@telecare.com.au

Our phone system may experience high volume inbound calls, please live chat with us on Telecare Website Live Chat

I agree to Telecare Terms of Use and Privacy Policy *

“If you are actively suicidal and/or contemplating significant self-harm, Telecare’s virtual care model may be insufficient for your needs. Please consider speaking to your GP, contacting your local crisis mental health team or presenting to your nearest Emergency Department.”

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