Service description Type of service Pre-Operation Consult Date: Surgery Date: Post-Operation Consult Date: Other Date: Description of service: EG How will the patient travel to the appointment? Has the patient been booked for the appointment? Is there any other information including any other out of pocket expenses that RWAV needs to be aware of? VISIT DETAILS Is the patient of Aboriginal or Yes No Torres Strait Islander descent? Will the patient be Yes No accompanied by a Carer? Travel type ACCHS Clinical Driver Commercial flight Patient or Carer’s Own Car How will the patient travel to the appointment? Hire car Taxi Other: Further details (as required): Visit length Number of days spent in the Number of nights for which accommodation How long will the patient stay at appointment location: is required for the appointment visit: the location of the appointment? Is there a cost for the Yes specialist appointment? No Not sure Is the applicant receiving funds for this service from another source? No Yes – please provide details: Are you able to provide the following to RWAV within one month of service delivery: An invoice to ensure reimbursement of costs? Yes No A service report detailing outcome? Yes No
Service description Type of service Pre-Operation Consult Date: Surgery Date: Post-Operation Consult Date: Other Date: Description of service: EG How will the patient travel to the appointment? Has the patient been booked for the appointment? Is there any other information including any other out of pocket expenses that RWAV needs to be aware of? VISIT DETAILS Is the patient of Aboriginal or Torres Strait Islander descent? Yes No Will the patient be accompanied by a Carer? Yes No Travel type How will the patient travel to the appointment? ACCHS Clinical Driver Commercial flight Patient or Carer’s Own Car Hire car Taxi Other: Further details (as required): Visit length How long will the patient stay at the location of the appointment? Number of days spent in the appointment location: Number of nights for which accommodation is required for the appointment visit: Is there a cost for the specialist appointment? Yes No Not sure Is the applicant receiving funds for this service from another source? No Yes – please provide details: Are you able to provide the following to RWAV within one month of service delivery: An invoice to ensure reimbursement of costs? Yes No A service report detailing outcome? Yes No
050-VicOutreach-Indigenous-Ear-and-Eye-Survey-Program-Application-Form.docx