Referral – Pharmacist at Home

Pharmacist at Home

Referrer’s Details

First Name

Last Name

Position

Organization

Phone/Mobile

Email

Client’s details

Has the client received services from WiseMed before?

Yes

No

First Name

Last Name

DOB

Gender

Address

Type of residence

How to access the home

Emergency contact details

First Name

Last Name

Phone/Mobile

Relationship

Email

Your Funding Options

Home Care Package / CHSP

NDIS Funding

NDIS Number*

Plan Start date*

Plan end date*

Is the NDIS *

Plan Managed

Self Managed

NDIA

Email

Referral information

How frequently would you like us to provide the service?

Past Medical History

Please upload Medical History Files (if available)

Choose File

Please provide the details of the treating GP for correspondence and coordination of care

GP Name

GP Practice*

Address

Email (if available)

Phone/Mobile

Confirmation

For correspondence and excellent coordination of care, WiseMed Services require a signed and dated authorization letter from a GP or other medical practitioner prior to commencement of services. WiseMed will endeavor to obtain it upon receiving the referral using the GP details provided in the referral form.

GP Authority

By submitting this referral, you acknowledge that WiseMed team will obtain it using the GP details provided above.

Client Consent

I have obtained consent from the client/patient to provide their personal health information to WiseMed Services for further assessment