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Referral Form
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Events
Travel Assistance Referral Form
Form must be completed by the client or by an authorised person on behalf of the client.
Fields marked with an * are required.
Title ie. Mr, Mrs, Ms:
Client First Name*:
Client Last Name*:
Client's date of birth* ie. dd/mm/yyyy:
Gender?*:
Male
Female
Aboriginal or Torres Strait Islander decent*:
Yes
No
Current pension concession card, health care card of DVA card?*:
Yes
No
If yes please supply card number:
Card expiry date:
Date and time
Residential Address*:
Postal address if different to above:
Client's telephone number:
Client's cancer diagnosis:
Referring Health Professional:
Health Professional Phone:
Do you require an escort?*:
Yes
No
If yes, escort's Title ie. Mr, Mrs, Ms:
If yes, escort's First Name:
If yes, escort's Last Name:
If yes, escort's date of birth ie.dd/mm/yyyy:
Appointment at ie. Hospital name, health centre, specialist*:
City/Town*:
Appointment date and time*:
Date and time
Appointment type*:
Consultation
Chemotherapy
Radiotherapy
Surgery
Mode of transport*:
Aeroplane
Bus
Car
Taxi
Do you require special assistance?* ie. Wheelchair, lift etc:
Yes
No
Client BSB number* (for VPTAS):
Client Bank Account Number* (for VPTAS):
Leaving Mildura on* (Preferred time):
Date and time
Returning to Mildura* (Preferred time):
Date and time
Client's email address*:
Full name of authorised person filling out this form*:
I agree to the terms and conditions (see below):
Yes
Security Captcha:
Answer the question below:
Please enter the second digit into the text box.
Terms and Conditions
By submitting this form I disclose I am experiencing financial difficulty. I give permission to the SCR Co-ordinator or their nominee to discuss my diagnosis with the referring health professional if needed. I give permission for this and any other relevant personal information to be sent to the VPTAS. If an escort/ Specialist is not approved by VPTAS, I understand I will need to reimburse the cost of travel to SCR. I have read and understand the Transport Assistance Guidelines.
I understand that a $15 dollar donation will need to be paid to Sunraysia Cancer Rescources before this form can be processed.
Non concession card holders will be charged the mandatory patient contribution i.e. $100 per treatment year for Victorian residents and $40 for New South Wales residents as per the State guidelines.
Sunraysia Cancer Resources
ABN
5068 1685 892
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