My Resident(s)

This form is for a clinical service provider - RACF
Please fill in as many details as possible and submit for GP referral

I wish to refer my resident(s) for Medication Review and clinical support regarding the safe and quality use of medicines as required by the Strengthened Aged Care Quality Standards: Standard 5: Clinical Care.

Circumstances where Medication Review and clinical support are required include (but are not limited to):

When care is commenced, transitions of care (e.g. hospitalisation or palliation) or annually

When there is a change in diagnosis or deterioration in behaviour, cognition or mental or physical condition, or when my client is acutely unwell

When there is polypharmacy (>5 medicines or >12 doses daily) and the potential to deprescribe

Starting a new medicine or a change to an existing medicine or medication management plan

When an adverse event, potentially related to medicines has occurred

When there is high-risk medicine use (e.g. opiates, antipsychotics, anticoagulants, antimicrobials, insulin, cytotoxics etc.)

Ensuring safe administration of medicines (e.g. swallowing difficulties)

Where medication information support would be beneficial

Your Details

Full name*

Care organisation

Facility name*

General Practitioner's Details

Full name*

Practice name*

Provider number

Email*

Phone*

Address*

Referral Forms

Contacts

My Resident(s)

Your Details

General Practitioner's Details

Resident(s) Details

I would like to enter care recipient(s) details one at a time

I would like to upload details for resident(s) who are all under the care of the above prescriber in bulk

Resident 1