Admission Form - Part 1 | Mayfield Aged Care

Aged Care Referal Codes
Respite Permanent

Respire Referral Code

Permanent Aged Care Referral Code

Applicant Details

Title
Mr Mrs Miss Ms

Date of Birth

Gender
Male Female

First Name

Preferred Name

Surname

Marital Status

Religion

Are you an Austraian citizen?
Yes No

Do you require an interpreter?
Yes No

Can family interpret?
Yes No

Place of Birth

Are you Aboriginal/Torres Strait Islander
Yes No

Are you enrolled to vote?
Yes No

Are You a Postal Voter?
Yes No

Income Status
Self Funded Full Pension Part Pension DVA Workers Compensation Third Party

DVA Number

Colour

Expiry Date

Pension Number

Expiry Date

Medicare Number

Medicare Expiry Date

IRN

NDIS

Do you have ambulance cover?
Yes No

What is your ambulance cover through
As a pensioner Via Private Health

Covid Vaccination Information

Date of each vaccination

Vaccination 1 Date

Vaccination 2 Date

Vaccination 3 Date

Vaccination 4 Date

When was your last flu vaccination?

When was your last Pneumovax Vaccination?

Allergies

Person Responsible

Primary Contact

First Name

Last Name

Mobile Number

Telephone Number

Email Address

Address

Postcode

Power of Attorney
Yes No

Restrictive Practices Substitute Decision Maker:
Yes No

Enduring Guardian
Yes No

Will the person be responsible for paying the accounts?
Yes No

Secondary Contact

First Name

Last Name

Mobile Number

Telephone Number

Email Address

Address

Postcode

Power of Attorney?
Yes No

Restrictive Practices Substitute Decision Maker?
Yes No

Enduring Guardian
Yes No

Will the person be responsible for paying the accounts?
Yes No

Correspondence

Please indicate your preferred option below.

Incident – Minor / No injury:
Phone Email

Times
24 Hours Specific Times

Please specify what time we can contact you for MINOR/No Injury Incidents

Incident - Major / Serious Injury
Phone Email

Times
24 Hours Specific Times

Please specify what time we can contact you for MINOR/No Injury Incidents

Resident Fee Statement

Resident fee statement is sent to one nominee. Please tick one option only:
Email Collect from Reception Give to Resident Post- cost of postage to be charged to account

Billing Email Address

Power of Attorney

Have you signed a Power of Attorney?
Yes No

Copy of power of attorneyMax file size 5mb

Name of person appointed under power of attorney

POA Phone Number

Guardian And/or Financial Manager

Have you appointed an Enduring Guardian or has a Guardian and/or Financial Manager been appointed?
Yes No

Copy of Appointment of Gurdian or Guardianship and/or Financial ManagementMax file size 5mb

If Guardianship or Fininacial Management Order made, date for review of order:

Other Details:

Are you currently residing in another Aged Care Facility?
Yes No

Name of facility

Date of Admission

General Practioner Details

General Practioner Name

General Practioner Phone Number

General Practioner Address

Postcode

General Practioner Email

Admission Form - Part 1

APPLICATION FOR ADMISSION PART 1

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