DT2URD Referral & Consent Form

DIETITIAN REFERRAL FORM
This form can be used for Home Care Package's, NDIS, Chronic Disease Management Plans, Medicare rebate, DVA, WorkSafe, TAC & Private Health clients.

After receiving the form we will contact you within 2 business days.

If you have any questions, please contact us at dietitian2urdoor@gmail.com
Who is this referral for?

MyselfFamily Member (Please list below)Client-from Health professional/Care Manager/Support Co-ordination (Please list below)Other (Please list below)
Name*

Clients First NameClient's Surname
Gender*
Date of Birth*

DayMonthYear
Date
Address*

Home Address/Visiting Address

Street Address Line 2

SuburbState

Postal Code
Phone
Mobile
Email*
example@example.com
Phone

Area CodePhone Number
Mobile
Family Member or Support Co-ordinator/Care Manager Email
example@example.com
GP's Name*
GP's Address*
GP's Phone*

Area CodePhone Number
GP’s Fax

Area CodePhone Number
GP’s Email
example@example.com
Please choose the applicable government/other funding sources you are using for the Dietitian visit?*
Please write down more information regarding the funding selection above?*
For Eg. NDIS information/number, HCP details/level, DVA number, Private Health Insurance cover details, etc
What is the main reason for seeing the dietitian?*
For Eg. I recently got out of hospital or rehabilitation, I am having bowel issues, My GP referred me for…, I am having trouble putting on weight etc
Please list any applicable medical conditions/co-morbidities?*
For Eg. Heart issues, Renal dysfunction, skeletal conditions, obesity, gastrointestinal issues, etc.
Please list any applicable medications ?*
Is there anything we should be made aware of?*
For Eg. Enteral Feeding/PEG, currently on supplements, mobility issues etc
Could you please provide any relevant files for us? These include, but are not limited to: NDIS Plan, DVA Referral letter/D904 form, GP's referral letter, Case Manager Plan, Blood test results etc
File Upload

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CONSENT TO COLLECT INFORMATION FOR DIETETIC ASSESSMENT & MANAGEMENT
Dietitian 2UR Door needs to collect information about you for the primary purpose of providing a quality service to you. In order to thoroughly assess, diagnose and provide therapy, we need to collect some personal information from you. Personal information and medical records are collected, used and disclosed for the following reasons:
- When communicating with other relevant treating doctors, specialists, allied health or care
- Communicating with you regarding our treatment/management, appointments & reminders;
- Billing purposes; HCP, NDIS, DVA, TAC, WorkSafe, Private Health Insurance and
- For legal related disclosure as required by a court of law.
We respect your right to decide how your personal health information is used or shared. Dietitian 2UR Door will take reasonable steps to ensure your privacy. If you have any concerns or wish to restrict access to your personal information, please discuss this with your Dietitian.

I understand:
- My participation is voluntary;
- I have the right to withdraw my consent;
- I have the right to cease consultations at any stage;
- I may access my medical records by written request;
- All electronic and paper records are kept secure to protect against unauthorised access;
- My referring doctor and/or health professional may be contacted in reference to my treatments
When you sign below you are consenting to:
- Receiving Dietetic assessment and management;
- A period of care which may involve several consultations within your home or residence;
- Confirming that you have read and understand the privacy policy*
- Communications via email, phone calls and/or text messages to a nominated email address and mobile phone number for administrative purposes and/or clinical care;
- The collection and sharing of information as outlined above.
Client Signature OR Support Co-ordinator Signature*

Clear
Client Name*
Date*

DayMonthYear
*Dietitian 2UR Door has a Privacy Policy located on their website www.Dietitian2urdoor.com.au. This provides guidelines on the collection, use, disclosure and security of your information. This Privacy Policy contains information on how you may request access to, and correction of, your personal information and how you may complain about a breach of your privacy and how we will deal with such a complaint.
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DIETITIAN REFERRAL FORM

CONSENT TO COLLECT INFORMATION FOR DIETETIC ASSESSMENT & MANAGEMENT