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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.
*
