Name of General Practice
Maximum 255 characters
0/255
Address of General Practice
Main contact person - Name
Main contact person - Role
Main contact person - Email
Main contact person - Phone
This expression of interest has been discussed and endorsed by the Practice Owner/s?
The Practice will have a dedicated room available for Dementia Australia to run the two clinics from 9:30am – 2:30pm
A Practice Nurse is willing and available to coordinate and attend the two clinics with Dementia Australia
Practice Nurse Name
Practice Nurse Email
Practice Nurse Phone
Please provide a brief outline of the Practice’s plan to ensure continuity of nursing duties while the Practice Nurse participates in the scheduled clinics.
Please outline the reasons your Practice should be considered for this opportunity, including how participation will benefit your Practice and patients with Dementia
Please provide an example of a quality improvement activity that could be implemented into the Practice if you are successful
Please indicate your Practice's preferred Round in order of first (1) to last (4)
If successful, the Practice Nurse agrees to participate in a short pre and post-survey to measure the success of the program
I understand that the provision of the funding grant is a once off PHN initiative to be used solely for the purpose of this activity
