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Home Care Provider Application
Home Care Provider Application
Client Details
Client Details
Title
First Name
Last Name
Address 1
Address 2
City
State
VIC
ACT
NSW
NT
QLD
SA
TAS
WA
Postcode
Contact Phone Number
Email Address
Date Of Birth
Health Detail
Health Detail
Fully Vaccinated for COVID
Fully Vaccinated for COVID
No
Fully Vaccinated for COVID
Yes
Does the client have problems with: (Tick all that apply).
Falls
Hearing
Memory
Diabetes T1
Mobility
Speech
Allergies
Diabetes T2
Heart Disease
Vision
Asthma / Airways
Medical details
Emergency Contact 1
The emergency contact should live within 30 minutes of the client - If only one contact is listed please select a key Lock
First Name
Last Name
Phone Number
Address 1
Address 2
City
State
VIC
ACT
NSW
NT
QLD
SA
TAS
WA
Postcode
Relationship To Client
Does this contact have a spare key?
Does this contact have a spare key?
No
Does this contact have a spare key?
Yes
Emergency Contact 2
The emergency contact should live within 30 minutes of the client
First Name
Last Name
Phone Number
Address 1
Address 2
City
State
VIC
ACT
NSW
NT
QLD
SA
TAS
WA
Postcode
Relationship to Client
Does this contact have a spare key?
Does this contact have a spare key?
No
Does this contact have a spare key?
Yes
Funding Agency
Funding Agency Details
Funding Agency Name
Agency Contact Name
Telephone Number
Invoice Postal Address
Billing Email Address
Funding Agency Email
Case Manager/Referrer Information
Case Manager/Referrer Information
Organisation
Suburb
Referrers First Name
Referrers Last Name
Contact Number
State
VIC
ACT
NSW
NT
QLD
SA
TAS
WA
We will use this email address to communicate to you about the application and keep you up to date with marketing information
Case Manager/Referrer's Email address
Services and Payment
Services and Payment
Type of Service Required
Home Only
Home and Mobile
Solo Watch
Home and Solo Watch
MePACS Solo Watch
40mm Cream Gold Watch
40mm Graphite Watch
44mm Graphite Watch
The client has good Telstra Mobile Phone coverage in their home
I can confirm
The watch needs to be charged regularly and I/the client is able to operate touch screen technology
I understand
Additional services
Key Lock
Additional Pendant
Daily Call
HCP Installation
MePACS to Install ($140)
Self-Installation and Postage (One Service) $29
Self-Installation and Postage (Two Services) $39
HCP to Install
Who should we contact for Installation
Client
HCP
Other - Provide details below
Additional Information
MePACS have a duty of care to ensure clients can access the service and easily raise an alert on the most appropriate device for them in the event of an emergency. I can confirm I have discussed the MePACS products and service with the client and received their consent to order.
