Accommodation Application and Consent Form

Name*

Preferred Name*

Current Address*

Street Address Suburb Postcode

Date of Birth*

Place of Birth*

Are you of Aboriginal or Torres Strait Islander origin?*

No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both Aboriginal & Torres Strait Islander

Marital Status*

Presenting Living Situation*

Facility Name*

Have you been a resident in another Aged Care Home previously ?*

Yes
No

If so, name of Facility

Date entered care

Has an ACAT Assessment been carried out?*

Yes
No

If yes, Please attach copy

Accepted file types: pdf, png, jpg, jpeg, Max. file size: 10 MB.

If your file is over 10mb, please send it to placements@maroba.com.au using a file transfer service such as wetransfer.com, Google Drive, Dropbox etc

ACAT Assessment*

Residential
Respite

Date ACAT was completed

Referral Code*

Has a DHS/DVA Income & Asset Test been completed?*

Yes
No

If yes, please attach copy

Accepted file types: pdf, png, jpg, jpeg, Max. file size: 10 MB.

If your file is over 10mb, please send it to placements@maroba.com.au using a file transfer service such as wetransfer.com, Google Drive, Dropbox etc

IF no, has it been lodged?*

Yes
No
Electing not to lodge

Type of Accomodation required*

Single
Shared room
Either

Name of Regular Doctor*

Phone No*

Address

Persons Responsible

Primary Contact

Person Responsible*

Relationship*

POA*

Yes
No

(if yes, please bring with you)

Receive Accounts

Yes
No

Enduring Guardianship*

Yes
No

(If yes. please bring with you)

Address*

Postcode*

Home Phone No*

Mobile*

Email*

Do you wish to receive our newsletter?

Yes
No

Secondary Contact

Person Responsible*

Relationship*

POA*

Yes
No

(if yes, please bring with you)

Receive Accounts

Yes
No

Enduring Guardianship*

Yes
No

(If yes. please bring with you)

Address*

Postcode*

Home Phone No*

Mobile*

Email*

Religion*

Medicare No*

Person number i.e. (1)*

Expiry*

Private Health fund

Yes
No

Expiry

Membership No

Name of Fund

Pension Received?*

Yes
No

Age*

Age
DVA / Service
Disability

Pension No*

Pension Frequency*

Part
Full

Expiry*

Colour of DVA card*

Funeral Fund Established?

Yes
No

Type

Cremation
Burial

Funeral director name

Cultural Background

Do you identify with a particular cultural group?

Yes
No

Do you have any cultural preferences for your care needs?

Do you have a will?

Yes
No

Location of Will

Electoral Role Status

Voting
Non-voting

How do you know about Maroba?*

Other*

Mr/ Mrs/ Miss/ Ms*

(Please print)

Signature*

Date*

Relationship*

Self Representative
Power of Attorney
Other

Other*

Any further comments to support the application?*

Consent to Collection, Use and Disclosure of Personal Information

In order for Maroba to provide you with the quality care and services outlined in your contract with us we collect from you, as a resident, particular personal and sensitive information. This includes and is not restricted to:

Name
Date of birth
Religion
Current address
Medical history
Family medical history
Medications
Social history
Other personal information including entitlement details, health care fund and country of birth

You may obtain access to the information we hold about you at any time.

In order for Maroba to provide you with the quality care and services outlined in your contract with us we collect from you, as a resident, particular personal and sensitive information. This includes and is not restricted to:

Name
Date of birth
Religion
Current address
Medical history
Family medical history
Medications
Social history
Other personal information including entitlement details, health care fund and country of birth

You may obtain access to the information we hold about you at any time.

Maroba may wish to display photographs or birthday notices throughout our facility or facebook page and website, possibly even marketing material. Are you happy for this to occur?*

Yes
No

At times, clinical photographs of a resident or client will be required for tracking progress, identification purposes, in evaluating the effects of their treatment and for communicating with other health care professionals who are involved in their treatment. Residents or clients (or other appropriate representative) have the right to access clinical photographs taken of themselves. I consent and understand that these photographs will only be used for this purpose.*

Yes
No

We also seek consent from you to disclose your personal information in, but not limited, to the following circumstances:

Display your name on the entry to your room and on tables at meal times
Discussions with other health professionals as needed
As required by other State or Federal legislation
To the person you have nominated as the 'person responsible' for giving and accessing your information

If we do not have your approval to disclose your personal information in these ways we may be unable to provide appropriate services and care or meet your individual requirements

I have read and understood the above and consent to the intended use and disclosures of the personal and sensitive information that Maroba holds

We also seek consent from you to disclose your personal information in, but not limited, to the following circumstances:

Display your name on the entry to your room and on tables at meal times
Discussions with other health professionals as needed
As required by other State or Federal legislation
To the person you have nominated as the 'person responsible' for giving and accessing your information

If we do not have your approval to disclose your personal information in these ways we may be unable to provide appropriate services and care or meet your individual requirements

I have read and understood the above and consent to the intended use and disclosures of the personal and sensitive information that Maroba holds

Name / Person Responsible*

Date*

Signature*

Witness (witnessed at Maroba)

Date

Signature

Mandatory Reporting

The Serious Incident Response Scheme (SIRS) is a government initiative to help reduce the risk of abuse and neglect for people living or staying in a residential aged care home. The scheme requires aged care providers to identify, record, manage, resolve and report all serious incidents that occur, or are alleged to suspected to have occurred, in a residential aged care service.

The SIRS requires every residential aged care service to adopt a systematic approach to minimizing the risk of, and responding to, serious incidents involving residents.

The SIRS underscores the vital importance of an incident management system in helping every residential aged care service to effectively manage risks to their residents.

A reportable incident includes any of the following:

Unreasonable use of force.
Unlawful sexual contact or inappropriate sexual conduct.
Neglect.
Psychological or emotional abuse.
Unexpected death.
Stealing or Financial coercion by a staff member.
In appropriate physical or chemical restraint; and
Unexplained absence from care.

Name / Person Responsible*

Date

Signature

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Name

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Accommodation Application and Consent Form

Persons Responsible

Primary Contact

Secondary Contact

Cultural Background

Consent to Collection, Use and Disclosure of Personal Information

Mandatory Reporting

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