Referral for Domiciliary Medication Management - Home Medicines Review
Medical Benefits Schedule Item 900. Also known as DMMR or HMR

Miscellaneous.Date

Patient	Community Pharmacy	General Practitioner	
Patient Demographics.Full Name
Patient Demographics.Address
Patient Demographics.Suburb  Patient Demographics.Postcode
Phone: Patient Demographics.Phone (Mobile)
DoB: Patient Demographics.DOB 
AGE: Patient Demographics.Age
Medicare no: Patient Demographics.Medicare Number
DVA no: Patient Demographics.DVA Number	DMMR Australia
Email:referrals@dmmraustralia.com.au
Phone: 03 4313 4122
Fax: 03 9960 2787	Treating Doctor.Name
Practice.Name
Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
E-mail: Treating Doctor.E-mail
Provider no: Treating Doctor.Provider Number
Prescriber no: Treating Doctor.Prescriber Number	

Medical History
Clinical Details.History List

Current Medications
Clinical Details.Medication List

Allergies
Clinical Details.Allergies

Immunisations
Clinical Details.Immunisation List

Relevant Progress Notes
Clinical Details.Selectable Encounter Notes

Relevant Pathology Results
Clinical Details.Result List (Selected)

Measurements
Clinical Details.Measurements

Social History	Occupation	
Clinical Details.Social History	Patient Demographics.Occupation	

Smoking status	Alcohol consumption	
Clinical Details.Smoking
Quitting stage: 	Clinical Details.Alcohol (Summary)	

Reason for referral for DMMR	Issues that may influence medication use	
Reason for referral	To select any item - highlight its checkbox and type x

p poor vision
p hearing problems
p swallowing difficulties
p dexterity
p language and/or literacy problems
p cognition
p other: please specify...

Medication Administration

Medication usually administered by 	Dosing Aids

p dosing aid device e.g. Dosett, Webster. Specify brand or type...

p other: please specify...

Disease Monitoring Devices

p peak flow meter
p BP monitor
p blood glucose meter
p INR monitor
p other: please specify...
	Medication Administration Devices

p spacer device for respiratory inhalers
p nebuliser pump for respiratory solutions
p other: please specify...

Interpreter required:  inter 
     
The patient's preferred language is... Preferred language

I HAVE EXPLAINED TO THE PATIENT
  the process in having a DMMR; and	THE PATIENT HAS CONSENTED:
   to me releasing to you information about Patient Demographics.his\her medical history and medications; and	
THE PATIENT UNDERSTANDS THAT:
   the location of the DMMR is at Patient Demographics.his\her choice, but preferably in Patient Demographics.his\her own home; and
   the pharmacist who will conduct the DMMR will communicate with me information arising from the DMMR; and	THE PATIENT HAS CONSENTED:
   to me releasing Patient Demographics.his\her Medicare no. or DVA no. to you for the pharmacist's payment purposes.
THE PATIENT HAS CONSENTED:
   to me releasing this information to DMMR Australia who utilises overseas contractors to assist in provision of this service.	

Signed.....................                                                     .            Date: Miscellaneous.Date

Treating Doctor.Name
Treating Doctor.Qualifications