Heart Health at Home Program

HEART HEALTH AT HOME PROGRAM

Cardiac Rehabilitaton Referral Form

Phone 1300 307 440 Fax 1300 880 378

Email: HeartHealthatHome@medibank.com.au

REFERRER DETAILS

Referrer name: *

Referrer role: *

Phone: *

Fax:

Email: *

REFERRAL AUTHORISATION (please ensure all are provided)

This patient is aware and has given consent for the information within this form to be provided to and to be contacted by the Medibank Heart Health at Home team *

YesNo

Is the patient a Medibank Member?

YesNo

Membership Number: *

Does the patient have a Smart Phone and access to download apps?

YesNo

Has the cardiac event happened in the past 60 days? *

YesNo

Referrers Signature:

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Date

If available please send through additional documents via fax to 1300 880 378

Discharge summaryMedication planOther relevant clinical information, please specify:

Please specify other:

PATIENT DETAILS

Name *

Date of Birth *

Address *

Phone *

Email *

PATIENT MEDICAL DETAILS (please ensure all fields are completed)

Cardiac Event Details - incl. reason for referral, relevant clinical details, risk factors:

Other Health Conditions & Relevant Medical History:

Please specify for Other

Other: any additional information relevant to referral

CLINICAL TEAM CONTACTS:

Treating Cardiologist: *

Cardiologist Phone:

Cardiologist Clinic/Address:

Regular GP:

GP Phone:

GP Clinic/Address:

If you have any questions about the Heart Health at Home program, please contact 1300 307 440

A Heart health at Home team member will contact the patient within 5 days of discharge date.

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