Applying for Residency

Please fill out the form below to apply for residency.

PLEASE COMPLETE ALL QUESTIONS IN THIS FORM

If the answer is unknown either enter “Unknown” or “Not Applicable” in the space provided.

Step 1 of 7

Care level*
Title*
Surname*
Given Names*
Date of Birth*
DD slash MM slash YYYY
Gender*
Country of Birth*
Town of Birth*
Main Languages Spoken*
Other Languages Spoken
Were you born overseas?*
- Yes
- No
If born overseas, date arrived in Australia*
DD slash MM slash YYYY
Are you an Australian citizen*
- Yes
- No
Are you an Aboriginal or Torres Strait Islander*
- Yes
- No
Marital Status*
Religion*
Former Occupation*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone Number*
Mobile Phone Number*
Income Status
Retirement Status*
DVA (type)
Other (Please Specify)
Have you had a respite stay in any Aged Care Facility at all in the past 12 months*
- Yes
- No
Pension Number*
Expiry Date*
DD slash MM slash YYYY
Medicare Number*
Expiry Date*
DD slash MM slash YYYY
Patient No. on Card*
Pharmaceutical Benefits Number*
PBS Safety Net number*
Health Fund name*
Membership Number & Scale*

PERSON RESPONSIBLE & FAMILY DETAILS PERSON RESPONSIBLE
Where a resident is at any stage unable to give directions or necessary consents to medical and other care, the Home may obtain such directions and consents from the ‘person responsible' for the resident. A ‘person responsible' is not necessarily the resident’s next of kin. A ‘person responsible’ is either:
- A guardian who has the function of consenting to medical, dental and health care treatments or, if there is no guardian;
- A spouse or de facto spouse with whom the person has a close, continuing relationship or, if there is no spouse or de facto spouse;
- An unpaid carer who is now providing support to the person or provided this support before the person entered residential care; or
- If there is no carer: A relative or friend who has a close personal relationship with the person.
Who would be your ‘Person Responsible’?
Name*
Relationship to you*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone Number*
Business Phone Number*
Mobile Phone Number*
Email Address*
Will the person responsible pay your accounts?*
- Yes
- No
Please provide details below:
IN THE EVENT OF EMERGENCY PLEASE CONTACT
(an emergency is a significant change in the resident’s medical condition)
Name*
Relationship to you*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone Number*
Business Phone Number*
Mobile Phone Number*
Do you wish this person to be contacted at any hour of the day or night?*
- Yes
- No
AM*

: Hours

Minutes
PM*

: Hours

Minutes

FUNERAL ARRANGEMENTS
Please complete if you have pre – arranged funeral arrangements you would like the facility to follow in the event of death:
Do you have a nominated funeral director? If yes, whom*
Do you have any special Religious/Cultural Requirements? Provide details.*
Special Requests – provide details*

DETAILS OF NEXT OF KIN (A PERSON’S CLOSEST LIVING BLOOD RELATIVE OR RELATIVE BY MARRIAGE / FAMILY).
Name*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Business Phone*
Mobile Phone*
Occupation*
Name of Business*
Email address*
Children/ Significant Persons
(If insufficient space, please attach separate list)
Name
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone
Business Phone
Mobile Phone
Occupation
Email
Name
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone
Business Phone
Mobile Phone
Occupation
Email
Name
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone
Business Phone
Mobile Phone
Occupation
Email

CURRENT RESIDENTIAL AGED CARE FACILITY
Are you currently residing in another Aged Care Facility?*
- Yes
- No
Name of Facility*
Date of Admission*
DOCTORS
General Practitioner*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone Number*
Is your Doctor willing to visit you at the home?*
- Yes
- No

NON-SMOKING POLICY:
Dubbo RSL Aged Care Association is a “smoke free” environment. Therefore, no resident is permitted to smoke within the confines of the entire facility except in designated smoking areas outside the building.
FINANCIAL INFORMATION:
Residential aged care fees and charges are strictly regulated by the Commonwealth Government and can vary depending on your financial circumstances. Information regarding your income and assets are required by the Admissions Department in order to determine the appropriate level of fees and charges to apply to your residency. For further information regarding Admissions Fees & Charges please refer to the ‘Residents Handbook’ enclosed in the Admissions Pack.
OTHER INFORMATION:
Other Information
Attach Files (250Mb Limit)
Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, txt, Max. file size: 250 MB, Max. files: 1.
PRIVACY CONSENT:
For the purposes of your residence (or proposed residence) at the Home and the services we provide to you, we will need to collect, record and use personal information about you (including medical and financial information). We may also sometimes need to disclose some of that information to: 1. Appropriate organisations, such as government departments (in Australia and, for some residents, in other countries), hospitals and other homes or hostels to which you may seek to move, and/or 2. Medical practitioners, other health service providers, professional advisers and other appropriate persons, such as guardians or other persons responsible under the Guardianship Act NSW (1987). In considering any disclosure to be made, we will bear in mind the maintenance of your privacy as an important criterion, subject to our need to perform our obligations and services. By submitting this form, you signify your consent to our collecting, recording, using and disclosing, as we consider appropriate from time to time, personal information in relation to yourself. If you wish to limit any disclosure we may make, would you please delete “Nil” below and specify the limitations you require. Absence of consent may not necessarily preclude the Home from collecting, recording, using or disclosing such information. A copy of the Home’s full Privacy Policy is available from our office. Limitations on Use or Disclosure (subject to the Home’s Privacy Policy) Nil
DECLARATION
By submitting this Application you declare that the information given in this form is true and complete, you give the undertaking set out above in relation to change to any Power of Attorney and/or appointment of Guardian or Financial Manager and you provide the privacy consent set out above.

Step 1 of 7

Income Status

PERSON RESPONSIBLE & FAMILY DETAILS PERSON RESPONSIBLE

Who would be your ‘Person Responsible’?

IN THE EVENT OF EMERGENCY PLEASE CONTACT

POWER OF ATTORNEY / FINANCIAL MANAGER

GUARDIAN OR ENDURING GUARDIAN / ADVANCED CARE DIRECTIVE (LIVING WILL) OR TREATMENT PLAN

FUNERAL ARRANGEMENTS

DETAILS OF NEXT OF KIN (A PERSON’S CLOSEST LIVING BLOOD RELATIVE OR RELATIVE BY MARRIAGE / FAMILY).

Children/ Significant Persons

CURRENT RESIDENTIAL AGED CARE FACILITY

DOCTORS

NON-SMOKING POLICY:

FINANCIAL INFORMATION:

OTHER INFORMATION:

PRIVACY CONSENT:

DECLARATION

Orana Gardens Estate, Dubbo

Orana Gardens, Dubbo