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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal details in Part 1, including your full name, date of birth, and DVA file number. Ensure all information is accurate.
In Part 2, provide detailed information about your injury, disease, or illness. Be specific about when the injury occurred and any medical treatment received.
If applicable, complete Part 3 for injury details or Part 5 for disease information. Include descriptions of how the injury happened and any relevant witnesses.
Attach any necessary supporting documents as indicated throughout the form, such as proof of identity and medical reports.
Finally, review all sections for completeness before signing the authorisation and declaration in Part 9.
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