New Client Registration
Basic Information
Title
First Name
Middle Name
Last Name
Preferred Name
DOB
Contact Information
Residential Address
Postal Address
Phone Number
Additional
MAC client number
Living arrangements
Accommodation setting
Indigenous Status
Country of Birth
Main language
Interpreter required
Employment status
Government pension/benefit
Department of Veteran Affairs (DVA) Status
Pension Card Status
Medicare
Primary Disability
Mobility
Does the client have any current health limitations that the driver should be aware of?
Carer's & Referral information
Carer info
Do you require a carer
Number of carers
Referral info
Name of the person making a referral
Organisation
Phone Number
Is client aware of referral?
Has the client given verbal consent to being referred?
Emergency contacts
ICE #1
Name
Relationship to the client
Address
Phone
[field id="emerg_phone2"]
Is the client willing that their information is given to the above person
ICE #2
Name
Address
Phone
[field id="emerg2_phone2"]
Is the client willing that their information is given to the above person
GP / Specialist
Name
Clinic
Clinic Address
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.
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
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
Notes & Additional Information
