Patient form expressing interest in a home medication visit

Name: *

D.O.B.: *

Contact Information

Email: *

Phone: *

Doctor’s name: *

Medical centre name and suburb: *

Would you like us to contact your GP and arrange a home medication visit for you?:

Yes

No (I will give your details to my doctor)

Do you:

Take more than 5 tablets

Had a recent change in medication

See more than 1 doctor

Suffer from a potential drug side effect

Recently been in hospital

Take warfarin, digoxin or thyroxine

Not getting a sufficient benefit from you medication

Trouble managing your tablets or devices (e.g. puffers)

Have language, physical or mental limitations

If you ticked any of the above items you are eligible for a free home medication visit.

Additional comments or queries:

Word verification: * Type the characters you see in this picture.

Type the characters you see in the picture above; if you can't read them, submit the form and a new image will be generated. Not case sensitive.