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Appointment attendance - (Form C)

Appointment attendance - (Form C)

Appointment attendance - (Form C)

Section A - Patient details

(patient, HHS or specialist to complete)

Date of birth * (DD / MM / YY)
Date of birth * (DD / MM / YY)
Section B - Evidence

(specialist to complete)

Part A: Please attach evidence of appointment attendance
Start Date * Appointment / Admission
End date * Appointment / Admission
Discharge Date * (DD/MM/YY)
(if not specialist)
I certify that the patient received specialist medical treatment as stated above.
Date * (DD / MM / YY)
(if not specialist)
(if not specialist)
Section C - Return travel

(if travel not booked, specialist or treating HHS to complete)

Date ready to travel home * (DD / MM / YY)
Travel home time
Recommended return mode of transport
If air, is a commercial flight medical clearance required?
Section D - Ongoing treatments

(specialist to complete)

Has the patient's treatment been completed?
If no, can future appointments be provided via Telehealth
Can ongoing treatment be provided at the patient's local hospital?
(approximate / TBA)
(name / location)
Patient escort requested
Admission type
Appointment type
Clinically recommended mode of travel
Hospital and Health Service use only
Section E - Additional appointment details

(clinicaian / clinician's nominated representative to complete)

Admission Date / Time * (DD/MM/YY) (HH/MM)
Admission type
Accommodation required
Patient escort required
Date * (DD/MM/YY)