Qantas referral | Clean Slate Clinic

Private health insurance

Does the employee have private health insurance with hospital cover? *

If they do, we ask their health fund to pay. If not, Qantas pays as their employer.

YesNo

Health fund *For example Bupa, Medibank, HCF, nib

Health fund membership number *

Health fund card: number next to their name *The number next to their name on the membership card

Referrer details

Your details, so we can update you on the referral.

Referring organisation *

Your full name *

Your role

Your email *

Your phone number *

Client details

First name *

Last name *

Preferred name

Date of birth (DD/MM/YYYY) *

Mobile number *Australian mobile, e.g. 0412 345 678

Email address *Needed to book their first appointment. Use the employee's own email if they have one.

Street address *

Suburb or town *

Postcode *

Gender

Sex assigned at birth

MaleFemaleOther

If other, please describe

Cultural and language information

Country of birth

Preferred language

Interpreter required? *

YesNo

Does the client identify as Aboriginal and/or Torres Strait Islander? *

YesNoPrefer not to say

Healthcare information

GP name

GP clinic and phone number

Medicare card number10 digits, as on the card. Leave blank if the client does not have one.

Medicare card: number next to their name (IRN)The number next to the client's name on the card

Card expiry (MM/YYYY)

Treatment type requested

Program *

Beyond Detox is for clients who want support to keep their goals after detox elsewhere, or after stopping.

If other, please describe

Clinical summary

A short summary of the client’s current situation and goals, and any relevant clinical information. Please include safety concerns, urgent needs and previous treatment.

Clinical summary *

Client consent

I confirm that the client has given informed consent for this referral to Clean Slate Clinic, agrees to be contacted by the clinic, and consents to the sharing and review of relevant information through appropriate channels to support coordinated care and the best health outcomes.

Yes, the client has given verbal or written consent

Referrer signature: type your full name *Typing your name signs this referral. It is dated automatically when you submit.

Refer a Qantas employee

Private health insurance

Referrer details

Client details

Cultural and language information

Healthcare information

Treatment type requested

Clinical summary

Client consent

Subscribe

Company

The program

Contacts