Online Client Application: DVA Clients Your DetailsName* First Last Address* Street Address Address Line 2 City State Postcode Mobile*Work PhoneEmail* Enter Email Confirm Email Date of Birth* Date Format: DD slash MM slash YYYY Referring Health Professional (eg Doctor) Details:Referring Health Professional Name:Referring Health Professional Address* Street Address Address Line 2 City State Postcode Referring Health Professional Email Please attach your referral here (D904 form)*View an example of a D904 form Section 2 - Dept. Veteran Affairs DetailsDVA Card: Please select* Gold Card Gold TPI White with accepted conditions White with PAMT DVA Number:*Screenshot of your MyService account accepted conditions*Please attach a screenshot of your MyService account (via your myGov login) that details your accepted conditions for the purposes of noting the exact medical wording for DVA claims. Please visit here for more informationDeclarationI understand and acknowledge that:* The above information is true to the best of my knowledge I will at all times be responsible for payment of my account in full I will need to provide payment of my account in full at private rates at the time of consultation until I have provided all of the information and documents required CAPTCHA
