For Existing Clients

Please fill this form in ONLY if you have used our services before.

If you are a new client, please use the next form.

Submission Preview

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Client Details

Client Name*

Client Address*

Client Phone*

Destination Address*

Appointment Details

Appointment Date*

Appointment Time*

Length of Appointment (in hours)*

Return or One Way Journey Required*

RETURN

ONE WAY

Number of Passengers*

Static Content

The above details are for a booking request only.

The booking is only confirmed after you have received a confirmation information from the Community Passenger Network coordinator.

For NEW Clients

Please fill this form in ONLY if you have NEVER used our services before.

If you are an existing client, please use the previous form.

Submission Preview

…

Client Details (NEW Clients)

Client's Name*

Known As

Residential Address*

Postal Address*

As Above

Enter a different address

Postal Address

Phone or Mobile*

Facsimile

Date of Birth

Date of Birth*

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.

Appointment Details

Destination Address*

Appointment Date*

Appointment Time*

Length of Appointment (in hours)*

Return or One Way Journey Required*

RETURN

ONE WAY

Number of Passengers*

Static Content

The above details are for a booking request only.

The booking is only confirmed after you have received a confirmation information from the Community Passenger Network coordinator.

Client Details

Marital Status*

Divorced

Married (reg/defacto)

Never Married

Not stated/inadequately described

Separated

Widowed

Living Arrangments*

Lives Alone

Lives with Family

Lives with Others

Not stated/inadequately described

Accomodation Setting*

Boarding house/private hotel

Domestic support living facility

Emergency/transitional accommodation

Independent living unit within a retirement village

Not stated/inadequately described

Other

Private residence - owned/purchasing

Private residence - private rental

Private residence - public rental

Private residence rented from Aboriginal Community

Psychiatric/mental health community care facility

Public place/temporary shelter

Residential aged care facility

Supported accommodation facilities

Temporary shelter within an Aboriginal Community

Indigenous Status*

Aboriginal but not TSI origin

Both Aboriginal and TSI origin

Neither Aboriginal and TSI origin

Not stated/inadequately described

TSI but not Aboriginal origin

Country of Birth*

Main language spoken at home*

Interpreter Required*

Yes

Employment Status*

Casual

Full Time

Not in paid employment

Not stated/inadequately described

Part Time

Seasonal

Government Pension or Benefit*

Aged

Carer Allowance

Carer Payment (pension)

Disability Support Pension

No government pension or benefit

Other government pension or benefit

Unemployment related benefits

Veteran Affairs Pension

Department of Veteran Affairs (DVA) Status*

Gold Card

White Card

NOT a DVA cardholder

DVA Card Number

Pension Card Status*

Not applicable

Pension card holder

Pension Card Number

Medicare Card Number*

Primary Disability*

Dementia (any stage of Dementia requires a carer)

Acquired brain injury

Autism (incl. Asperger's syndrome)

Deaf blind (dual sensory)

Frail aged & elderly

Hearing (sensory)

Intellectual (including Down's Syndrome)

Neurological (including Epilepsy & Alzheimer's)

None

Other

Physical

Psychiatric

Specific learning (incl. ADD)

Speech (sensory)

Vision (sensory)

Carers Contact Details (If Required)

Telephone

Mobile

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

Mobility*

Independent

Walking aides required e.g. walker, stick

Wheelchair dependent

Disabled

Referral

Name of Person making the referral

Organisation

Contact Number

Is client aware of referral?

Yes

Has the client given verbal consent to being referred?

Yes

Emergency Contact (Preferred)

Name*

Relationship to client*

Address*

Telephone or Mobile #1*

Telephone or Mobile #2

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

Yes

Emergency Contact #2

Name

Address

Telephone or Mobile #1

Telephone or Mobile #2

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

Yes

GP/Specialist

Name*

Name of the clinic*

Address

Telephone

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

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

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

Notes & Additional Information

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

Booking

For Existing Clients

Client Details

Appointment Details

For NEW Clients

Client Details (NEW Clients)

Appointment Details

Client Details

Referral

Emergency Contact (Preferred)

Emergency Contact #2

GP/Specialist

Costs/Reimbursements

Client Consent