DVA Referral Form

Thank you for visiting our website, this form is intended for Agencies or Case Managers wishing to refer clients who are GOLD or WHITE Card Holders under a Rehabilitation Appliances Program (RAP) or a Coordinated Veterans Care (CVC) Program . Once you submit this form, we will aim to contact your client or nominated person within 24 hours to offer an appointment. When an appointment is secured, we will then email and notify you of this.

Referral Type

Referral

SpecialistAllied Health Provider

Card Type

GoldWhite

Service Selection

If the client was deemed suitable, would they consider a Telehealth appointment?

YesNo

Patient Details

First Name

Last Name

DVA File Number

Date of Birth

Contact Number

Street Address

Email Address

Accepted Disabilities

Condition to be Treated

Is the patient a resident in a Residential Aged Care Facility?

YesNo

Emergency Contact/Next of Kin

Emergency Contact Name

Relation

Emergency Phone Number

Referrer Details

Referrer First Name

Referrer Last Name

Organisation

Referrer Phone Number

Referrer Email

Please upload any additional documents (Medical Summary / Brokerage Agreement)

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