Admission Enquiry Please complete the form below, and when finished click the 'Submit' button. Are you enquiring for yourself or a loved one?*MyselfA loved one NameFirstLast Name of Person Making EnquiryFirstLast Relationship to Ptential Resident Email Phone* Prefered Form of Contact*E-MailPhone Type of Stay*Select TypePermanentRespite Assessed Level of Care*Select LevelNot AssessedRest HomeRest Home High NeedsHospital What type of room interests you? (check all that apply)Standard RoomLarge RoomPrivate DeckShared ToiletPrivate BathroomSuite & Lounge PaymentSelect typePrivateSubsidisedPotential Resident's Information Potential Resident's NameFirstLast Date of Birth*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year NHI #* Does the potential resident have an EPOA?*YesNo Has the EPOA been activated?YesNo EPOA NameFirstLast EPOA Phone Current ResidenceSelectLiving at HomeRetirement VillageAnother Rest Home Which Rest Home is the potential resident currently at? List any health issues.* List any medications and the reasons for them. Which mobility aids are used? (select all that apply)Walking StickWalkerWheel ChairMobility ScooterOther Any mobility aids used?*YesNo How many falls has the potential resident had in the previous 12 months?* List any dietary requirements? Can the potential resident feed themselves without assistance?*YesNo List any hearing or vision imparements and aids. List any memorry/congative issues, including any demintia. Are there any behavioural or anger issues? If not type "none".* Anything else?Thank you for taking the time to complete our enquiry form. One of our lovely team will be in touch with you soon. Have a nice day.SubmitReset
