Name*Preferred Name*Current Address* Street Address Suburb Postcode Date of Birth* DD slash MM slash YYYY Place of Birth*Marital Status* Married Single Widowed Divorced SeparatedPresenting Living Situation* Living with Family Renting own House or Unit Retirement Village Unit Residential Aged CareFacility Name*Have you been a resident in another Aged Care Home previously ?* Yes NoIf so, name of FacilityDate entered care DD slash MM slash YYYY Has an ACAT Assessment been carried out?* Yes NoIf yes, Please attach copyAccepted file types: pdf, png, jpg, jpeg, Max. file size: 32 MB.ACAT Assessment* Residential RespiteDate ACAT was completed DD slash MM slash YYYY Referral Code*Has a DHS/DVA Income & Asset Test been completed?* Yes NoIf yes, please attach copyMax. file size: 32 MB.IF no, has it been lodged?* Yes No Electing not to lodgeType of Accomodation required* Single Shared room EitherName of Regular Doctor*Phone No*AddressNominated RepresentativePrimary ContactNominated Representative*Relationship*POA* Yes No(if yes, please bring with you)Receive Accounts Yes NoEnduring Guardianship* Yes No(If yes. please bring with you)Address*Postcode*Home Phone No*Mobile*Email* Do you wish to receive our newsletter? Yes NoSecondary ContactNext of Kin*Relationship*POA* Yes No(if yes, please bring with you)Receive Accounts Yes NoEnduring Guardianship* Yes No(If yes. please bring with you)Address*Postcode*Home Phone No*Mobile*Email* Religion*Medicare No*Person number i.e. (1)*Expiry*112345678910111213141516171819202122232425262728293031Month123456789101112Year202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Private Health fund Yes NoExpiry DD slash MM slash YYYY Membership NoName of FundPension Received?* Yes NoAge* Age DVA / Service DisabilityPension No*Pension Frequency* Part FullExpiry* DD slash MM slash YYYY Colour of DVA card*Funeral Fund Established? Yes NoType Cremation BurialFuneral director nameCultural BackgroundDo you identify with a particular cultural group? Yes NoDo you have any cultural preferences for your care needs?Do you have a will? Yes NoLocation of WillElectoral Role Status Voting Non-votingHow do you know about Maroba?* Relative previous resident Friend/ relative recommended Online search My Aged Care Hospital recommended Always known about Maroba OtherOther*Mr/ Mrs/ Miss/ Ms*(Please print)Signature*Date* DD slash MM slash YYYY Relationship* Self Representative Power of Attorney OtherOther*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?* Yes NoAt 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.* Yes NoWe 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* DD slash MM slash YYYY Signature*Witness (witnessed at Maroba)Date DD slash MM slash YYYY SignatureCAPTCHAEmailThis field is for validation purposes and should be left unchanged.