Refer a DVA Patient - VitalCall | Medical Alert System

Note:

National Guidelines for the supply of a Personal Response System (PRS) are available on the internet at: http://www.dva.gov.au/providers/provider-programmes/rehabilitation-appliances-program-rap#national-guidelines. Prescribers are advised to take into consideration the criteria listed in the guidelines before prescribing a PRS.

Personal Details

Client First Name *

Client Surname *

Date of Birth *

DVA File Number *

Card Type *

Gold White - confirmed eligibility with DVA

Client Address *

Suburb *

State *

Postcode *

Access Information (e.g. one way street, lot number) *

Phone Number (include area code) *

LMO Name *

LMO Phone Number (include area code) *

Recommended Appliance *

Wrist Trigger Pendant Personal Response System Hostel/Retirement Village Pendant Only Requests
(send to DVA and include name, phone and fax number of facility) Non-Monitored Alarms
(send to DVA and include name, phone and fax number of facility)

VitalCall does not currently provide non-monitored alarms.
Please contact DVA for more information.

Recommendation *

New Installation

Takeover of Existing Alarm by Eligible Spouse

Name of existing company

Current Residence *

House or Unit Rental Department of Housing

Criteria - Note: The criteria listed below is a summary of the criteria required to be considered prior to prescription of a PRS to be supplied by the Department.

This person lives alone Either This person does not live alone but is without assistance OR This person does not live alone, but his/her carer is unable to provide or obtain assistance
(e.g. due to significant hearing impairment, dementia or mobility problems) OR

The entitled person should meet one or more of the following criteria prior to the provision of a personal response system

This person has a significant risk of medical emergencies Either This person has a recent history (within the past 12 months) of falls
(The falls must have been investigated and the cause of the falls eliminated where possible. Therefore personal response systems should only be considered if there is a continued risk of falls) OR This person displays a number of factors that would put them at high risk of a fall
(Risk factors include severe visual impairment, severe mobility and balance problems, severe incontinence, and medical conditions which aect balance and mobility (such as Parkinson’s or Meniere’s Disease)) OR

The entitled person must meet all of the following criteria prior to the provision of a personal response system.

Person has sufficient physical function to operate the PRS

Person has sufficient cognitive function to wear and operate the Pendant and PRS

Person has a willingness to wear the Pendant 24 hours a day

Person has a willingness to activate the PRS if necessary and test once each month

If applicable, use this section to expand on any previous sections including important medical conditions, allergies, or other personal details.

Additional Info/Notes *

Technical Information

Type of phone (e.g. Std, VoIP etc.) *

Number of phones / phone sockets and locations *

Proposed location of PRS unit *

Phone service supplier *

Is a power point available solely for the PRS unit near the phone? *

Yes No

Is there a Broadband Internet connection or fax machine in use? *

Yes No

Is there an active NBN Connection? *

Yes No

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Prescriber Information

First Name *

Last Name *

Provider Number *

Phone Number (include area code) *

Fax Number (include area code) *

Email Address *

Do you recommend supply? *

Yes No

I verify that the above details are correct

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Emergency Contact Details

Name 1

Relationship

Address

Suburb

State

Postcode

Phone number (include area code)

Mobile number

Any restrictions

Name 2

Relationship

Address

Suburb

State

Postcode

Phone number (include area code)

Mobile number

Any restrictions

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Assessment Form for the supply of a Personal Response System

Personal Details

Technical Information

Prescriber Information

Emergency Contact Details

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