Winter Strategy 2018 Patient Registration

Person/practice submitting the form

Your name*

First Last

Email*

Note: the following patients are not eligible for enrolment:

Under the care of palliative care team
Enrolled in Coordinated Veterans Care program
Under 18 yrs old
Patients with little to gain from enhanced care through the flu season. (e.g not high risk or care is already optimised)

Winter ID*

Winter ID codes were provided to your practice on completion of the enrolment form. Range WS180000 to WS189999

I have obtained the patient's consent and provided them with the information sheet*

You must obtain consent from the patient before registering them.

Patient Name*

First Middle Last

Patient DOB*

dd/mm/yyyy

Indigenous status

Patient Address*

Street Address Address Line 2 City State Postcode

Patient Sex*

Patient's GP Name*

Prefix First Last

GP Provider Number*

This is required for the purpose of establishing Admission/Discharge Notifications.

This section requests data which will be used to evaluate the Winter Strategy 2018.

Please tick all boxes which apply to the patient being enrolled in Section 2.

Currrently Active Chronic Conditions*

Tick all that apply

Chronic Conditions (Other)

Currently Active Co-morbidities*

Tick all that apply

Co-morbidities (Other)

Social Impacts*

Care Planning

Tick all that apply

Phone

This field is for validation purposes and should be left unchanged.