Additional visit request

If you are an existing RWAV Outreach contract holder and need to request any additional visits, please complete the form below and a member of our outreach team will be in touch to discuss this with you.

If you have any questions or require assistance please call (03) 9349 7800 or email vicoutreach@rwav.com.au.

Additional visit request (existing contract holders)

Contract reference number*
Name*
First Last
Phone*
Email*
Proposed number of additional visits*
Proposed number of sessions (if applicable)
When do you anticipate the requested visit/s to be completed? (Please provide the proposed visit date/s)

Please note: RWAV is not in the position to support retrospective visits and proposed visits within 7 business days of submitted request.
Please provide a brief description of the service need eg. service demand/ waiting list, percentage of bulk-billed services*
Max 500 words
Other requests eg. changes to contact details*
Max 500 words
*
I certify that all information I have provided as part of my application is true & honest.
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