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.

Gender?*:
Aboriginal or Torres Strait Islander decent*:
Current pension concession card, health care card of DVA card?*:
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Do you require an escort?*:
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Appointment type*:
Mode of transport*:
Do you require special assistance?* ie. Wheelchair, lift etc:
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I agree to the terms and conditions (see below):
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.
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