Personal Care Assistance Request Form-0045

PERSONAL CARE ASSISTANCE REQUEST (Form-0045)

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

First NameLast Name
Date*

DayMonthYear
Date
Skymac is able to offer you a range of personal care services outside of what is included in the cost of your fortnightly rent/board.

These services are listed below, and it is important to note that they are not included in your board and lodging (rent). If you would like Skymac to provide you with any of these additional services, you need to let us know by completing the following checklist.
Which of the following services would you like Skymac to assist you with:*

Personal hygiene (showering, oral hygiene, shaving, grooming)Toileting, bladder and bowel movements and menstrual careAdditional room cleaningPersonal laundry and extra linenEating / drinkingMobility (walking, transfers from sitting/standing/lying, stairs)Dressing / undressingUse of aids and appliances, hearing and communication devicesAssistance with continence aids
By signing below, you request that Skymac assists you with the Personal Care Services selected above.

You also understand that you can amend or terminate this request at any time and seek the assistance of an external service provider if you wish.
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:

PERSONAL CARE ASSISTANCE REQUEST (Form-0045)

Resident’s Details

Signature of Resident

In the presence of (Witness)