HPN New Patient Request Form (NZ Config) | Baxter Professional Australia

Intended for Australian Healthcare Professionals only

Patient Details

First Name

Last Name

Gender

Date of Birth

Address

Suburb

State

Post Code

Email Address

Home Phone

Mobile no.

Preferred Delivery Day

Mon

Tue

Wed

Thus

Fri

NOTE: This is to indicate preference of delivery day only. Baxter will confirm the delivery day once the account is set up.

Alternate Contact Information

First Name

Last Name

Relationship to Patient

Home Phone Number

Mobile no.

Email Address

Referring Healthcare Professional Details:

Referring Hospital

Home PN Co-ordinator (key contact for contact for all therapy and billing queries)

First Name

Last Name

Job Title

Phone Number

Email Address

Billing Information

Home PN Solution should be charged to (confirm paying hospital)

Home PN Solution PO Number

Consumables should be charged to (confirm paying hospital)

Consumables PO Number

Additional Billing Contact

Phone Number

Email Address

Hardware Required

Allow up to 5 working days for delivery of hardware. Accessories (IV pole, backpacks and trolleys) can be requested in the consumables list. For product details please log into Baxter Professional.

Pumps

Pumps quantity - month

Pump Delivery Date

Pump Deliver to

Giving sets

Giving sets quantity - month

Giving Sets Delivery Date

Giving Sets Deliver to

Is a box of giving sets required to be set with the pump delivery?

Yes

Specific Delivery Address for Hospital

Ambulatory Pump Training

Please allow at least 2 weeks notice for pump training to be scheduled, this allows for hardware delivery prior to training.

Estimated date of discharge

Pump Training Required

Yes

Requested Training Date

Consumables Required

Select items required, quantity (lowest possible unit of measure), frequency. Additional rows will display as required. This information will form the regimen for monthly consumables orders and assist us in conducting stocktakes with the HPNer. For product details please log into Baxter Professional.

Consumables Product Category

Quantity

Frequency

Special requirements

Terms and Conditions

HPNer would like to receive an SMS reminder for consumables stocktakes to be completed and orders to be placed.

HPNer consents to phone number being included on delivery consignments

HPNer agrees to be at the nominated delivery address on the arranged delivery days for HPN and consumables

Hospital and HPNer are aware of and agree to Equipment On Loan Terms and Conditions

The Hospital, by its authorised representative, requests (as relevant) Baxter Healthcare Pty Limited or Baxter Healthcare Limited (each “Baxter”) to loan that Equipment listed above for use by the Patient subject to and in accordance with the Equipment loan terms and conditions accessible electronically on Baxter’s web site at www.baxterhealthcare.com.au and clicking on the ‘Equipment Loan Terms’ tab for Australia and New Zealand. The provision of this Request constitutes acceptance of those terms and conditions by the Hospital. If the Hospital has a separate Supply or Service Agreement signed by Baxter and currently governing these arrangements, the terms and conditions contained in that other agreement applicable to the supply of this Equipment will prevail to the extent of any inconsistency. It should be noted that if an IV Pole, Back Pack or Trolley are included in this Request, they will not be supplied under the Equipment loan terms and conditions and title will be transferred to the Hospital as free of charge Deliverables under the terms of the Contract (unless the Contract provides for a charge).