All questions must be answered as accurately as possible so as to enable the home to assist you. Your application will remain valid for twelve(12) months, unless the nursing care centre is notified otherwise. Should the care needs and/or personal details alter, please advise the nursing care centre of the changes.
PERSONAL DETAILS:
Surname:
Given Names:
Address:
Postcode:
Telephone:
Date of Birth:
Sex:MaleFemale
Religion:
Marital Status:WidowedMarriedDivorcedSingle
CONTACT DETAILS:
Please list first the person who will be responsible for payment of your fess whilst a resident.
Name:
Relationship:
Phone: (h) (w)
(h)
(w)
PENSION DETAILS:
Type of Pension:
Pension Number:
Name on Pension:
Safety Net Number (if known):
OTHER DETAILS:
Medicare Number:
Name on Medicare Card:
Member of a medical and/or hospital benefits organisation:YesNo
Membership Number:
Scale:
