Application for Admission form - St Paul de Chartres Residential Aged Care

Application date*

Admission details

Applicant (person requiring residential care)

Applicant Name*

First Last

Date of Birth*

Preferred name*

Gender*

Male
Female
Other

Marital status*

Home phone number*

If you do not have a home number, please enter your mobile number.

Mobile phone number*

If you do not have a mobile number, please enter your home number.

Level of care*

Permanent care
Respite care

Representatitve*

If Yes please provide details below

Yes
No

If Representative, please provide details here.*

Person Completing the application details

Name*

First Last

Address

Street Address Address Line 2 Suburb State Postcode Country

Home phone number*

Mobile phone number*

Work phone number

Email address

Relationship to applicant*

Name of your primary decision maker*

First Last

First contact details

Is the First Contact the same person who is completing this application form?*

If you tick YES, you do not have to fill this in. Please go to the Second Contact Details section.

Yes
No

First contact name*

First Last

Address*

Street Address Address Line 2 Suburb State Postcode Country

Home phone number*

Mobile phone number*

Work phone number

Email address*

Relationship to applicant*

Second contact details

Second contact name*

First Last

Address

Street Address Address Line 2 Suburb State Postcode Country

Home phone number*

Mobile phone number*

Work phone number

Email address

Relationship to applicant*

Fees – Statement & Correspondence to be sent to the following.

Is the same person who is completing this application form?*

If you tick YES, you do not have to fill this in. Please go the Medical Details section.

Yes
No

Name*

First Last

Address

Street Address Address Line 2 Suburb State Postcode Country

Home phone number*

Mobile phone number*

Work phone number

Email address

Relationship to applicant*

Medical details

NOTE: Full medical details will be required on admission.

Who is your current General Practioner?*

First Last

Address*

Street Address Address Line 2 Suburb State Postcode Country

Phone*

 If you have a current, detailed summary of your health – Please upload a copy

Max. file size: 256 MB.

Have you completed an Advance Health Directive?*

Yes
No

Do you have Private Health Insurance? (e.g. MBF, Medibank Private)*

Yes
No

Name of Fund*

Level of cover*

Health Fund membership number*

Medicare number*

Expiry date*

Medicare card refrence number

Seniors health care number

Expiry date

Fire/Emergency rating*

Mobile
Mobile with assistance
Bedfast
Wheelchair/assist

Weight range

30-60kg
61-85kg
86-104kg
105kg plus

Other details

Religion*

Country of birth*

Main language*

Legal and Financial Management Details

Have you completed the Centrelink Combined Asset Assessment?*

Yes
No

Based on that Assessment are your Assets between?*

$0 - $50,500
$50,501 - $171,500
More than $171501

Pension type*

DSS.Full
DSS.Part
DVA.Full
DVA.Part
No Pension

Pension number

Pension expiry date*

DVA status*

Gold
White
Other
No DVA card
Not applicable

Have any of the following people been appointed on your behalf?*

PLEASE NOTE: If you check any of the above boxes, Certified Copies will be required on admission.

Guardian
Administrator
Enduring Power of Attorney (Financial)
Enduring Power of Attorney (Personal & Health)
Power of Attorney (Financial only)
Not applicable

If yes, please provide the names and addresses of persons/organisations appointed*

First Last

Address*

Street Address Address Line 2 Suburb State Postcode Country

Phone*

Name

This field is for validation purposes and should be left unchanged.