Physicians x Veteran intake Form

Patient Details

Name: *

Date of Birth *

Email address: *

Phone:

What gender do you identify as? *

Identify as Aboriginal/Torres Strait Islander?

Yes No Choose not to say

Billing Details

Which of the following is most suitable?

I have a DVA Card.I have a Medicare CardI have applied for a Medicare CardI do not have a Medicare Card

DVA Card *

Card Number

How to apply for a Medicare Card

Agent Details

Do you have a DVA agent? (RSL, Open Arms or other organisation? *

YesNo

Agents name & branch if known: *

Agents Email address *

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

Specialtist Required

GP Referral *

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Supporting Documents

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Supporting Documents

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Supporting documents

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Additional comments:

173, Whitehorse Road, Blackburn, VIC 3130.

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.