Home Care Package - Revital Heathcare

A PROUD PROVIDER OF HOME CARE PACKAGE

HOME CARE PACKAGE FORM

As you grow older, you may find that you need extra support to continue living at home. This is where a Home Care Package can help.

A Home Care Package is a government-funded program that allows older people to receive care services in their own home, so they can live independently for as long as possible. It can be used to receive all kinds of support, such as help with housework, transport to appointments or personal care.

A Home Care Package gives you choice and control over your care. Once you have received a package, you are free to choose us as your provider to work with you to create a care plan that best meets your needs. The government then subsidies our services to your home.

Participants Details

Name

Phone No.

Street Address:

Date of Birth:

Doctor's Name:

GP Clinic:

Next of Kin Information

Name:

Relationship to Client:

Phone No.

Email Address:

Street Address:

If Applicable:

HCP Company:

Case Manager:

Case Manager Phone Number:

Case Manager Email:

Type of Referal:

Physiotherapy Occupational therapy Dietetics Allied Health Assistant

Reason for referral (include past medical history)

Relevant Documentation

I consent to receiving an assessment and treatment from the chosen health care services at Revital Healthcare

Treatment Conditions

Please note that all appointments are subject to our 24-hour cancellation policy. If you can’t make your appointment, please notify your treating professional at least 24 hours before it is scheduled. If you miss an appointment due to being unavailable and did not give notice, the full fee will be charged, however we will give consideration to unforeseen circumstances.
Revital Healthcare does not accept responsibility for the treatment received by the participant. The patient and individual therapist are responsible for any professional liability.
Revital Healthcare has assurance protocols in accordance with each relevant governing health service body and clinical guidelines.

Consent Details

To be completed either by the client or the client’s representative or next of kin

Name:

Signature (required):

Date

Relationship to participant (if being completed by guardian/parent):

I accept the above terms and conditions. (required)

I consent to receiving an assessment and treatment from a physiotherapist at Revital Healthcare. (required)

A PROUD PROVIDER OF HOME CARE PACKAGE

HOME CARE PACKAGE FORM

Participants Details

Next of Kin Information

If Applicable:

Treatment Conditions

Consent Details

We look forward to working together towards your goals, here at Revital Healthcare

Contact Us

michael@revitalhealthcare.com.au

+61 425 241 311

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