Application for Residential Aged Care

Applicant’s representative

Does the applicant have a representative?

Yes No

Title

First name

Surname

Street Address

Suburb

State

Postcode

Country

Phone

Mobile

Relationship to applicant

EPOA Guardian

Where is the correspondence regarding this application to be posted?

Applicant Applicant’s representative Other (please specify)

Other

Medical details

Do you have a General Practitioner who has agreed to provide medical care for you at TLC Aged Care?

Yes No

If yes, it is essential that your doctor agrees to visit you at TLC Aged Care or provide a locum service to you, outside of normal business hours, in the event of illness or injury.

If no, there are doctors who routinely visit TLC Aged Care residences. You may choose to have one of these doctors as your nominated Medical Practitioner.

Please provide your current General Practitioner’s details:

General Practitioner’s name

Practice name

Street Address

Suburb

State

Postcode

Country

Phone

Mobile

Fax

Pharmacy details

Do you currently have your prescription(s) held by a pharmacy?

Yes No

If yes, please provide your pharmacy details below.

Pharmacy name

Street Address

Suburb

State

Postcode

Phone

Fax

Emergency contact 1

Title

First name

Surname

Street Address

Suburb

State

Postcode

Country

Phone

Mobile

Relationship to applicant

Emergency contact 2

Title

First name

Surname

Street Address

Suburb

State

Postcode

Country

Phone

Mobile

Relationship to applicant

Previous aged care residential accommodation details

Have you ever been a permanent resident in another aged care organisation?

Yes

If yes, please provide the following details:

Facility Name

Street Address

Suburb

State

Postcode

Country

Phone

Fax

Date of permanent admission

Retention rate

Accommodation charge

Bond or Refundable Accommodation Deposit ($)

Interest Rate

Comments

Click here for details of the TLC Aged Care privacy policy.

Security ^*