New Veteran Onboarding Form

Welcome to Total Veteran Healthcare

Privacy statement - We respect your privacy and are committed to safeguarding your personal information. All data collected during your intake process is confidential and will only be used for the purpose of providing you with quality healthcare services. We adhere to all legal and ethical standards to protect your information and will not disclose it to third parties without your explicit consent, except as required by law. By signing this form, you acknowledge and consent to the use of your information for treatment purposes within our healthcare system

Are you an existing veteran with Total Veteran Healthcare? *

YesNoUnsure

General Information

First name *

Middle Name

Surname *

Date of birth *

Gender *

Email Address *

Mobile phone *

Home phone

Current Home Address: *

Street address *

City *

State *

Postcode *

Do you identify as Aboriginal or Torres Strait Islander

Emergency Contact Information

Emergency contact *

Phone *

Emergency contact’s relationship *

Service Information

Armed Service *

ArmyNavyAir Force

Time in Service *

Discharge Date *

DVA Card/File Numbers + Accepted Conditions

DVA Card Number *

Card Type *

WhiteGoldNot Sure

DVA File Number (if known)

Referring Doctor

Referring Doctor Name

Referring Doctor Address

Usual General Practitioner Name

Usual Practitioner Address

Power of Attorney

Do you have an enduring power of attorney? *

YesNo

If yes, please provide their name

If yes, please provide their phone number

Current and Desired Health Services

Supporting Documentation

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Coordinated Veteran Care (CVC) Plan

If you are a "Gold Card" or a "White Card" holder with an "Accepted Mental Health Condition" - Are you on a Coordinated Veteran Care plan? - Select one of the following *

I AM NOT a Gold Card or a White Card holder with a accepted mental health condition eg PTSD, Depression disorder, Anxiety disorder, Alcohol use disorder, Substance abuse disorder.YES I HAVE undertaken a Coordinated Veteran Care Plan and i'll have it sent to your practice.NO I HAVE NOT but I will with my local GP and i'll have it sent to your practice.NO I HAVE NOT and I would like the Total Veteran Healthcare team to undertake this is for me.I AM UNSURE and would like to know more from a Total Veteran Healthcare team member.

Please upload a copy of your CVC, if already completed.

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Eligibility

Where I am not eligible for my desired services, please refer my details to an Advocate to review my healthcare entitlements. *

YesNo

Consent

I confirm that above information I have provided is true, complete and accurate. *

Signature *

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Date *

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