Chronic Disease Management (CDM) referral.

Formerly Enhanced Primary Care (EPC). GP-referred Medicare allied health sessions for patients with a chronic or terminal medical condition.

Client Information

Client's Full Name*

Client's Date of Birth*

Client's Gender

Client's Medicare Number

Client's Phone*

Client's Email*

Client's Address

Used for billing purposes. If not provided we'll confirm at intake.

Services Requested

What services is the client interested in?*

Clinical Information

Please send any relevant medical information to admin@healthsocietyco.com.au

Client's Primary Diagnosis*

Reason for Referral*

Client's Goals*

Relevant Medical History / Attached Reports

Other treating practitioners, previous therapy, surgical history. Note any attached reports.

Availability for Clinic Appointments*

Recommended Treatment Frequency*

Contact to Book the Appointment*

If someone other than the client manages their clinic bookings (e.g. carer, support coordinator, family member), please provide their name and number.

Chronic Disease Management (CDM) Details

Formerly Enhanced Primary Care (EPC).

Number of Sessions Allocated*

Number of allied health sessions approved on the GP management plan.

Referral Date*

Date on the CDM/EPC referral form.

Clinical Details

Chronic condition(s), recent illness, and current medications relevant to this referral.

Referring Practitioner

Practitioner's Full Name*

Role / Profession*

Practice / Organisation

Provider Number*

Referrer's Phone*

Referrer's Email*

Additional Information

Cultural or Additional Information

How did you hear about Health Society Co.?*

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By submitting this form you confirm you have the client's consent to share their information with Health Society Co.