Practice Visit Request

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* 1. Practice Name

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* 2. Practice Address

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* 3. Contact Person

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* 4. Phone:

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* 5. I would like our practice visit to be conducted via

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* 6. 1st preference appointment date & time

Date / Time

Date

Time

AM/PM

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* 7. 2nd preference appointment date & time

Date / Time

Date

Time

AM/PM

My practice is interested in: (Please select options from questions 8 - 12)

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* 8. Safety and Quality

5th ed. accreditation standards

Cold Chain Management

Infection Control

Continuous Quality Improvement

Dealing with difficult behaviour

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* 9. Person and Coordinated Care

Tasmanian Health Pathways

eReferral

After Hours care

Team based care

Health Literacy

Aboriginal and Torres Strait Islander health

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* 10. Digital Health

Patient health apps

My Health Record

Tasmanian Health Directory

Telehealth with hospital outpatients

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* 11. Population Health

Primary health Information Network (data sharing and quarterly reports)

Chronic Disease Management (MBS items and using the clinical audit tool to target patient care)

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* 12. Other

I would like the following resources delivered (maximum quantity noted in Qty field where applicable)

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* 13. I would like the following resources delivered (Quantity to be delivered in brackets)

	Yes
Tasmanian HeathPathways Guide (Max Qty 15)	Tasmanian HeathPathways Guide (Max Qty 15) Yes
Translator and Interpreter Service (TIS) kit (Max Qty 1)	Translator and Interpreter Service (TIS) kit (Max Qty 1) Yes
Medical Director and Pracsoft manual set (Max Qty 1)	Medical Director and Pracsoft manual set (Max Qty 1) Yes
Train IT video library (clinical and management software)	Train IT video library (clinical and management software) Yes
GP Antenatal Shared Care Pregnancy Record (Northern region only) (Max Qty 50)	GP Antenatal Shared Care Pregnancy Record (Northern region only) (Max Qty 50) Yes
Share Transfers of care kit (Max Qty 6)	Share Transfers of care kit (Max Qty 6) Yes
After Hours magnets for patients (Max Qty 100)	After Hours magnets for patients (Max Qty 100) Yes
Digital Health Guide introduction (Max Qty 15)	Digital Health Guide introduction (Max Qty 15) Yes
Tasmanian Health Directory booklets (Max Qty 15)	Tasmanian Health Directory booklets (Max Qty 15) Yes