APPLY FOR AGED CARE WAITING LIST

    PERSONAL DETAILS

    Aged CareDementia Specific

    This form must be completed by the applicant or person responsible, and returned with a copy of the following Assessments emailed to info@glengollan.com.au:

    • ACCR (Aged Care Assessment)
    • Permanent Residential Aged Care Request for a Combined Assets & Income Assessment
    Title:
    Other:
    Surname*:
    Given names*:

    Your date of birth* (DD-MM-YYYY):

    Male
    Female
    Indeterminate / Intersex / Unspecified
    Country of birth*:
    Religion:

    Languages spoken:

    Phone:
    Mobile*:

    Email*:

    Address*:

    Postal address:

    NEXT OF KIN - PERSON #1

    Surname*:
    First name*:
    Phone:
    Mobile*:

    Email*:

    Postal address:

    Relationship:

    NEXT OF KIN - PERSON #2

    Surname:
    First name:
    Phone:
    Mobile:

    Email:

    Postal address:

    Relationship:

    Where is Applicant presently being cared for?

    Is Applicant’s Doctor prepared to attend our facility? YesNo

    Name:

    Address:

    Phone:

    Pension number*:

    Pension type*: AgedVet Affairs
    Level of Pension*: FullPartSelf Funded
    Medicare number*:
    Expiry* (MM-YYYY):

    Preferred accommodation*: SingleSharedEither

    How did you find out about Glengollan?:

    I wish to apply for my name to be placed on the waiting list at Glengollan Residential Aged Care. I understand that a place will only be made available to me after I have had a further interview with the Glengollan Residential Aged Care.*