Submit A Facility Request

(9am-4pm Monday to Friday)

If this is a medical emergency DO NOT use this form, and contact 000 instead.

Examples of emergencies include: chest pain, acute shortness of breath, head injury, persistent distress.

Please only submit requests for residents currently registered.

Between 9am and 4pm Monday to Friday, a nurse will be in contact with you within 4 hours.

Outside of these hours, your request will be handled the next business day.

Please fill in all the fields and provide as much detail as possible.

Missing fields and lack of information will delay us responding to you.

Your Name *
Subject *
Your Role: *
Is this a notification for the GP or a request for review? *
Priority *
Facility Name: *
Resident First Name: *
Resident Last Name: *
Resident's Date of Birth: *
Regular GP Name for the Resident: *
Facility Phone Number: *
Your Email:*
Current problem the Resident has (include what observation have you done Obs (BP, P, T, oxygen level, Resp rates, FWT, Neuro obs, pain management chart, PRN analgesia given): *
Background to the situation (include: History, examination, relevant test results, management relevant information, what have you done so far): *
When we call you back, who should we speak to about this enquiry? Please write the name of the responsible person for this issue: *
What Type of Drug Charts Do You Use?: *