Booking Form - Virtual Specialist Consults

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Patient Details

Full Name *

Gender *

DOB *

Street Address *

State

Post Code *

Email Address *

Phone Number *

Medicare Number

Medicare Expiry Date

Number on card

Patient's Regular GP Clinic *

Interpreter Required *YesNo

Interpreter Language *

I have a confirmed diagnosis of ADHD *Yes

Are you of Aboriginal and/or Torres Strait Islander origin? *YesNo

Would you like the Aboriginal Health Nurse to give you a call earlier on the day of your appointment? *YesNo

Would you like an Aboriginal Health Nurse to attend your appointment with you? *YesNo

Has the patient used the VED service to obtain ADHD medication in the last 6 months *YesNo

How many days of medication do you have left? *

The Doctor who usually prescribes and manages my ADHD medication is *

I am currently taking the following medication (please include dose) for my ADHD *

The pharmacy where I last collected my medication was *

Reason for Referral

As part of providing safe care, our clinicians may need to access relevant health information about you. *This may include: SafeScript, a real-time prescription monitoring program for high-risk medicines, including commonly prescribed medicines used to treat ADHD. Please see https://www.health.vic.gov.au/drugs-and-poisons/safescript for further information. My Health Record – read more https://www.health.gov.au/topics/health-technologies-and-digital-health/my-health-record?language=en) In addition, a clinician may obtain further important information regarding your care from the medical practitioner and/or pharmacy nominated on this registration form.I consent to the Virtual Specialist Consult team accessing relevant information from the sources listed above on my behalf to support the safe delivery of my care.

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Patient Details

Full Name *

Gender *

DOB *

Email Address *

UR Number

Patient's Regular GP Clinic *

Interpreter Required *YesNo

Interpreter Language

The patient has a confirmed diagnosis of ADHD *Yes

Are you of Aboriginal and/or Torres Strait Islander origin? *YesNo

Would you like the Aboriginal Health Nurse to give you a call earlier on the day of your appointment? *YesNo

Would you like an Aboriginal Health Nurse to attend your appointment with you? *YesNo

Has the patient used the VED service to obtain ADHD medication in the last 6 months *YesNo

How many days of medication does your patient have left? *

The Doctor who usually prescribes and manages the patient's ADHD is *

The patient is currently taking the following medication (please include dose) for their ADHD *

The pharmacy where the patient last collected their medication was *

Reason for Referral

As part of providing safe care, our clinicians may need to access relevant health information about you. *This may include: SafeScript, a real-time prescription monitoring program for high-risk medicines, including commonly prescribed medicines used to treat ADHD. Please see https://www.health.vic.gov.au/drugs-and-poisons/safescript for further information. My Health Record – read more https://www.health.gov.au/topics/health-technologies-and-digital-health/my-health-record?language=en) In addition, a clinician may obtain further important information regarding your care from the medical practitioner and/or pharmacy nominated on this registration form.The patient consents to the Virtual Specialist Consult team accessing relevant information from the sources listed above on my behalf to support the safe delivery of my care.

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Patient Details

Full Name *

DOB *

Street Address *

State

Post Code *

Email Address

Mobile Number *

Medicare Number

Medicare Expiry Date

Number on card

Referral Reason *Chronic Obstructive Pulmonary DiseaseInterstitial Lung DiseaseOther Lung Disease

Patient is willing to participate in Virtual Pulmonary Rehabilitation *YesNo

Has the patient been admitted to hospital within the past 4-weeks due to a respiratory cause? *YesNo

Interpreter Required *YesNo

Is the patient currently on Oxygen? *YesNo

Interpreter Language

We cannot accept this patient currently

Referral Information

Referrer Details

Referring Physician/Healthcare Professional’s Name *

Profession *

Organisation *

Name of (Office) Contact *

(Office) Phone *

(Office) Fax *

(Office) Email Address *

Street Address *

State

Post Code

Regular GP Details

GP Name

GP Phone Number

Street Address

Post Code

Additional Files

Please email the most recent clinic notes or healthcare summary and RFT/imaging results to vvpr@nh.org.au, to enable referral processing.