Assistance with Tobacco Management Form-0054

ASSISTANCE WITH TOBACCO MANAGEMENT REQUEST (Form-0054)

Personal Care Services – Level 3 Approved Accreditation – Additional Fees and Charges Apply
Resident’s Details
Name*

First NameLast Name
Date*

DayMonthYear
Date
I hereby request management/staff of Skymac to assist me with managing my tobacco. I understand that:
- smoking is a health hazard and I choose to do so at my own risk.

- Skymac will use allocated funds in my Resident Spending Account in accordance with my nominated budget to purchase my choice of tobacco.

- Skymac is authorised to store my tobacco in a locked area within the facility.

- my tobacco is distributed to me under my requested budgeted conditions.

- should I choose to revoke my decision for assistance it must be in writing and must be a full request to cease any assistance.
Signature of Resident

*Or signature of person acting on authority under Guardianship Administration Act 2000 or Powers of Attorney Act 1998 for the person named above, OR an Informal Decision Maker (must have an Informal Decision Maker Details Form-0071 signed) for the person named above.
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
In the presence of (Witness)
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

ASSISTANCE WITH TOBACCO MANAGEMENT REQUEST (Form-0054)