Facility Contact Form

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Geriatric Care Australia is not an emergency service
If you are concerned about that your resident is deteriorating or critically unwell please contact ambulance services immediately by calling 000.

This Facility Contact Form is designed gather important clinical information about changes in a residents condition. Please write relevant, short and clear descriptions in the spaces provided below. If questions don't apply please leave blank.

Facility Information

Facility Name

Your Name

Your Email (where a copy is sent)

Your Role: *

Nursing Staff (RN, EN & AIN)

Facility / Care Manager

Care Staff

Allied Health

Resident Information

First Name

Last Name

Date of Birth

Main reason for contact? *

Fall

Pain

Weight

Behaviour Change

Skin Integrity

Infectious Disease

Family Appointment

Other

Fall Description:

Pain Description:

Skin Integrity Description:

Behaviour Change Description:

Infectious Disease Description:

Weight Description:

Family Appointment

Other:

Please propose the clinical need below: *

Emergency: Call 000 immediately

High Priority: Telehealth

Routine: Next GP Round

Please provide resident vital signs:

Signature

Geriatric Care Australia collects information for the primary purpose of providing quality healthcare. We ask for personal details and a full medical history so that we may properly assess, diagnose and treat illnesses and be pro-active in healthcare delivery. We will also collect, hold, use and disclose the information you provide in accordance with the Privacy Act 1988 and Australian Privacy Principles (March 2014).

I confirm that I have the authority and appropriate permissions to share the patient’s information provided in this form. The information is accurate and complete to the best of my knowledge. I understand this request is for clinical support from GCA Primary Care, and I will continue to monitor the patient and provide necessary immediate care as appropriate while awaiting a response.

Your Signature

Thank you for contacting us, we will be in contact within the appropriate timeframe. You will receive a copy of this submission to the provided email address. For emergencies please call 000 immediately.

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Geriatric Care Australia

A For-Purpose Organisation

Email: admin@geriatriccareaustralia.com.au
Office Hours: Monday to Friday: 9:30am to 5:00pm

Phone: (02) 9160 0079

For Patients & Family

For Community Providers

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