Name*Preferred Name*Current Address* Street Address Suburb Postcode Date of Birth* Date Format: DD slash MM slash YYYY Place of Birth*Marital Status*MarriedSingleWidowedDivorcedSeparatedPresenting Living Situation*Living with FamilyRentingown House or UnitRetirement Village UnitResidential Aged CareFacility Name*Have you been a resident in another Aged Care Home previously ?*YesNoIf so, name of FacilityDate entered care Date Format: DD slash MM slash YYYY Has an ACAT Assessment been carried out?*YesNoIf yes, Please attach copyAccepted file types: pdf, png, jpg, jpeg.ACAT Assessment*ResidentialRespiteDate ACAT was completed Date Format: DD slash MM slash YYYY Referral Code*Has a DHS/DVA Income & Asset Test been completed?*YesNoIf yes, please attach copyIF no, has it been lodged?*YesNoElecting not to lodgeType of Accomodation required*SingleShared roomEitherName of Regular Doctor*Phone No*AddressNominated RepresentativePrimary ContactNominated Representative*Relationship*POA*YesNo(if yes, please bring with you)Receive AccountsYesNoEnduring Guardianship*YesNo(If yes. please bring with you)Address*Postcode*Home Phone No*Mobile*Email* Do you wish to receive our newsletter?YesNoSecondary ContactNext of Kin*Relationship*POA*YesNo(if yes, please bring with you)Receive AccountsYesNoEnduring Guardianship*YesNo(If yes. please bring with you)Address*Postcode*Home Phone No*Mobile*Email* Religion*Medicare No*Person number i.e. (1)*Expiry* Date Format: DD slash MM slash YYYY Private Health fundYesNoExpiry Date Format: DD slash MM slash YYYY Membership NoName of FundPension Received?*YesNoAge*AgeDVA / ServiceDisabilityPension No*Pension Frequency*PartFullExpiry* Date Format: DD slash MM slash YYYY Colour of DVA card*Funeral Fund Established?YesNoTypeCremationBurialFuneral director nameCultural BackgroundDo you identify with a particular cultural group?YesNoDo you have any cultural preferences for your care needs?Do you have a will?YesNoLocation of WillElectoral Role StatusVotingNon-votingHow do you know about Maroba?*Relative previous residentFriend/ relative recommendedOnline searchMy Aged CareHospital recommendedAlways known about MarobaOtherOther*Mr/ Mrs/ Miss/ Ms*(Please print)Signature*Date* Date Format: DD slash MM slash YYYY Relationship*Self RepresentativePower of AttorneyOtherOther*Any further comments to support the application?*Consent to Collection, Use and Disclosure of Personal InformationIn 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:NameDate of birthReligionCurrent addressMedical historyFamily medical historyMedicationsSocial historyOther personal information including entitlement details, health care fund and country of birthYou 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?*YesNoAt 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.*YesNoWe 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 timesDiscussions with other health professionals as neededAs required by other State or Federal legislationTo the person you have nominated as the 'person responsible' for giving and accessing your informationIf 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 requirementsI have read and understood the above and consent to the intended use and disclosures of the personal and sensitive information that Maroba holdsName / Person Responsible*Date* Date Format: DD slash MM slash YYYY Signature*Witness (witnessed at Maroba)Date Date Format: DD slash MM slash YYYY SignatureCAPTCHANameThis field is for validation purposes and should be left unchanged.