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Client Registration

Please use this form when travelling for the FIRST TIME with us.

You MUST register before booking a trip with us and only need to do this once. Returning customers do not need to register.

Client Consent

To Ensure the client is able to make an informed decision about consent to the disclosure of information, staff should:

Read the client their rights and responsibilities and post a hard copy to the client.
Explain that the clients information will only be released to any other services or used in auditing purposes if the client agrees.
Advise that the referral for service can still proceed if the client does not want information disclosed.
Is the client willing for staff to advocate on their behalf to re-align appointment times and days to align with available vehicles.
The client is aware that the information given is true and correct and will be in a a confidential database

Title

First Name

Middle Name

Last Name

Preferred Name

Date of Birth

Residential Address

Postal address if different from above

Phone Number

If you are 65 or older, you must register with My Aged Care (MAC). Phone 1800 200 422

If you are already registered please enter the client number below.

Living Arrangements

Accommodation Setting

Indigenous Status

Country of Birth

Main Language Spoken at Home

Interpreter required?

Employment Status

Government Pension or Benefit

Department of Veteran Affairs (DVA) Status

Pension Card Status

Medicare Card Number

Primary Disability

Mobility

Does the client have any current health limitations that the driver should be aware of?

Do you require a carer

Yes No

Number of carers

Emergency Contact #1

Name

Relationship to the client

Address

Phone #1

Phone #2

Is the client willing that their information is given to the above person

Yes No

Emergency Contact #2

Name

Address

Phone #1

Phone #2

Is the client willing that their information is given to the above person

Yes No

GP/Specialist

Name

Name of the Clinic

Clinic Address

Clinic Phone Number

Costs / Reimbursements

Fares: Is the client aware that the medical bus is a set fare only with no concessions. Carers may travel FREE but be responsible for your continued support during the trip.

Yes No

Volunteer Transport: is run by a Fee for Service system, Fees cover the running costs of the vehicle. This will be explained when making a booking. Fee for Service has been explained

Yes No

The client is aware of other reimbursement schemes available to them. PATS (Patient Assistance Transport Scheme) Hospital reimbursements: Flinders, Lyell McEwin, Modbury, QEH, RAH, Women's & Children's

Yes No

Notes & Additional Information

65367

You are welcome to make a booking straight after completing this registration process. If you have any questions, please contact us on 8842 1677

Make a booking

Please call us on

8842 1677

or email on cpn@cgvc.sa.gov.au

If you have never used our services before, you MUST register first above.

65367

The Network

The Mid North Community Passenger Network has 8 cars based at the following locations within the Mid North Region.

Clare
Balaklava
Burra
Hamley Bridge
Eudunda
Mallala
Riverton

We are committed to the safety of our clients and volunteers and have implemented the following measures to keep everyone safe.
From SA Health the mandatory requirements are:

When travelling with the network we ask that you (and carer) wear a mask during the entire trip.
You are required to check in via QR code or the contact tracing sheet. This will be only required once a trip.
You must allow the driver to sight the green tick if using QR code check in.
If you have a cold or flu we will not be able to provide travel services to you.

Have you used our services before?

Client Registration

Client Consent

Make a booking

8842 1677

The Network

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COVID-19 safety

Services

Volunteers

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