Compensation Claim - Veteran intake Form

Appointment Request *

Initial Assessment (Pre-claim Medical Diagnosis and Reporting - GP referral is required for each specialty)Comprehensive IME (Post-claim Independent Medical Examination and Reporting) Other

Patient Details

First Name *

Surname *

State *

Home Address *

Postcode *

Email address: *

Phone: *

Date of Birth *

What gender do you identify as? *

DVA Details

How to apply for a Medicare Card

Military Advocate Details

Do you have a military advocate? *

YesNo

Advocate name & branch if known:

Advocate Email address and phone number

Patient history

Relevant service *

Medication History *

Medical history *Please write N/A if not applicable

Social historyPlease mention: 1] Living situation (Own/Rent/Board/Other) 2] Dependents if any 3] Education (Primary/Secondary/Tertiary)

Additional HistorySmoking, Alcohol / Other drugs

Family History of major illnessesIncluding mental health.

Current functional impacts of service history

GP Referral *

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Supporting Documents

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Supporting Documents

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Supporting documents

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Supporting Documents

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Additional comments:

Consent

Cancellation/Missed appointments:

Please understand that our specialists (and your GP where applicable) have reserved their time for you. If you must cancel your appointment, we respectfully request 48 hours notice so we have time to organise another patient who needs this service. Missed appointments, or appointments cancelled without valid medical reason within 48 hours of the appointment will incur a fee ($150). This fee is not covered by the Department of Veterans Affairs.

Surcharge:
Credit card surcharge applies (1.7% + 20c per transaction)
Contact our rooms for bank transfer details. Electronic funds transfers must be received into Telecare's account no later than 72 hours prior to your next appointment - all oustanding invoices must be paid prior to a rebooking,

*

I confirm the above information I have provided is true, complete and accurate *

Signature *

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Today's Date *

How Telecare Manages Your Information

Telecare's Privacy Policy

For other inquiries, contact Telecare
173 Whitehorse Road, Blackburn, VIC 3130
Head Office Ph 03 9052 4872
veteran@telecare.com.au
Veteran department Ph 03 6153 0066

Telecare acknowledges the Traditional Owners of the land on which we live and work, the Wurundjeri People of the Kulin Nation. We pay our respects to Elders past, present and emerging.

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