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.*