SWICK Early Intervention Form

Patient / Injured Worker Details

Full Legal Name

First NameLast Name

Patient Date Of Birth

DD/MM/YYYY

Patient Email

example@example.com

Patient Phone Number

Please enter a valid phone number.Format: (+61) 0000-000-000.

Injury Details

Injury

Date Of Injury

DD/MM/YYYY

Background Information

Injury Management Advisor/Representative Details

Full Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (+61) 0000-000-000.

Email (a confirmation email will be sent to this address)

example@example.com

Please provide your preferred appointment requirements.

We will endeavour to schedule the closest available day and time to suit your requirements and will email you with the appointment details once confirmed.

Perferred Date

Date

AM or PM? Choose all that apply.

Western Australia or Queensland?

WA Clinics

QLD Clinics

Additional Comments/Notes

Services Requested For SWICK (Select Multiple If Appropriate)

SWICK Pre-Approved Early Intervention Package Include:

Allied Health:

1 x initial + 2 x subsequent appointments approved for allied health.
Further sessions may be approved with IMA approval.
Short email/phone call (6 mins communication code) following 1st and 3rd session outlining:
- Incident occurrence, symptoms reported, impression/diagnosis
- Recovery expectations/timeline, and expected return to work progression.
No formal reporting required.
$250 limit on consumables – seek IMA approval for anything above.

GP:

Initial GP for work certificate + a final or further work certificates to be provided if change of duties are required.
IMA approval required for any additional scans or investigations.

Relevant Documents/Reports

Please review both links below to our privacy policy prior to completing the form. https://www.redimed.com.au/privacy-policy/

https://www.redimed.com.au/terms-and-conditions/

If multiple discipline services are required, costings will be as per each allied health service separately.
All costings are aligned with the respective state-based Workers Compensation gazetted rates.
Costs are inclusive of all approved consultations, consumables, communication and reports, in line with the state-based Workers Compensation gazetted rates.
Invoicing is completed following each session and will be itemised with consult, report, communication and consumables

I have read the structure of RediMed's Early Intervention Program and understand, agree and consent to the associated early intervention package.

SWICK Early Intervention Referral