Podiatry Request Form

Please complete the following details in order that Healthcare 2 You can provide podiatry treatment for your resident/loved one. Please note, this is NOT a referral form.

Resident Name*
Facility Name & Section*
Date Of Birth*
DD slash MM slash YYYY
Medicare Number*
Medicare Expiry
DD slash MM slash YYYY
DVA Gold Card (if applicable)
GP Details*
Level of Care*
- High Care
- Low Care
Approval*
- Management Approval for Podiatry
  Approval entitles Healthcare 2 You to invoice the facility for Podiatry treatment
- Resident and Family Approval for Podiatry
  Approval entitles Healthcare 2 You to invoice the resident/family/POA for Podiatry treatment for which the resident/family/POA will be responsible.
Billing Details
Address*
Street Address City State Postal Code
Phone*
Email*
Name*
Relationship to Resident*
Signature*
Date*
MM slash DD slash YYYY

NB: If you are a DVA Gold Card holder, a referral from the doctor needs to be obtained before your consultation.

Eligible patients can receive up to 5 treatments at no cost with a referral from a doctor. Please ask the podiatrist how you can organise this or contact our office online or via phone at 1300 882 374.

Podiatry Request Form

Billing Details