New Client Registration

Basic Information

Title

[field id="title"]

First Name

[field id="name"]

Middle Name

[field id="middlename"]

Last Name

[field id="lastname"]

Preferred Name

[field id="preferredname"]

DOB

[field id="dob"]

Contact Information

Residential Address

[field id="streetaddress"], [field id="town"] [field id="pc"]

Postal Address

[field id="postal_address"], [field id="postal_town"], [field id="postal_state"] [field id="postal_pc"]

Phone Number

[field id="phone"]

Email

[field id="email"]

Additional

MAC client number

[field id="mac_number"]

Living arrangements

[field id="livingarrangements"]

Accommodation setting

[field id="accommodation"]

Indigenous Status

[field id="indigenous"]

Country of Birth

[field id="countryofbirth"]

Main languageĀ 

[field id="mainlanguage"]

Interpreter required

[field id="interpreter"]

Employment status

[field id="employmen_status"]

Government pension/benefit

[field id="govt_benefit"]

Department of Veteran Affairs (DVA) Status

[field id="dva"]

Pension Card Status

[field id="pension_card"] [field id="pension_card_no"]

MedicareĀ 

[field id="medicare"]

Primary Disability

[field id="primary_disability"]

Mobility

[field id="mobility"]

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

[field id="health_issues"]

Carer's & Referral information

Carer info

Do you require a carer

[field id="require_carer"]

Number of carers

[field id="number_of_carers"]

Referral info

Name of the person making a referral

[field id="referral_name"]

Organisation

[field id="referral_organisation"]

Phone Number

[field id="referral_phone"]

Is client aware of referral?

[field id="aware_of_referral"]

Has the client given verbal consent to being referred?

[field id="referral_consent"]

Emergency contacts

ICE #1

Name

[field id="emerg1_name"]

Relationship to the client

[field id="emerg1_relationship"]

Address

[field id="emerg1_street_address"], [field id="emerg1_city"] [field id="emerg1_pc"]

Phone

[field id="emerg_phone1"]
[field id="emerg_phone2"]

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

[field id="share_info_1"]

ICE #2

Name

[field id="emerg2_name"]

Address

[field id="emerg2_street_address"], [field id="emerg2_city"], [field id="emerg2_state"] [field id="emerg2_pc"]

Phone

[field id="emerg2_phone1"]
[field id="emerg2_phone2"]

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

[field id="share_info_2"]

GP / Specialist

Name

[field id="gp_name"]

Clinic

[field id="clinic"]

Clinic Address

[field id="clinic_address"], [field id="clinic_city"], [field id="clinic_state"] [field id="clinic_pc"]

Clinic Phone

[field id="clinic_phone"]

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.

[field id="cost_awareness"]

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

[field id="fee_explained"]

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

[field id="aware_other_reimb"]

Notes & Additional Information

[field id="notes"]