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Patient Information

DVA Card Number

Practitioner Information

Treatment Goals

Treatment Plan

Medication Recommendations:
▪ Medication Name ▪ Dosage ▪ Route ▪ Frequency ▪ Purpose ▪ Side Effects
▪ Medication Name ▪ Dosage ▪ Route ▪ Frequency ▪ Purpose ▪ Side Effects
▪ Medication Name ▪ Dosage ▪ Route ▪ Frequency ▪ Purpose ▪ Side Effects

Allied Health 

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Behavioural Modifications

▪ Topic ▪ Patient Input ▪ Resources Provided

Referrals Required

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Assessments and Monitoring

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Management Goals / Recommendations

Informed Consent for Social Worker Services

The purpose of the following is to inform you about the provision of social worker services by Medilinks Australia Online Pty Ltd t/as VBA Health (“us”, “we” “Proactive Health”) and for you to consent to receive social worker services from us and to our management of your personal information.

Part A

Social Worker Services

Type of Services

Social worker services include the following supports:

Part B

Management of Health and Medical Information

Collection of Personal Information

As part of providing social worker services to you, we need to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information. This collection of personal information will be a necessary part of the services that are provided.