New Aged Care Client Form

New Aged Care Client Form
Facility Details
Legal Name
Trading Name
ABN
Group
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your postal address different to your physical address?

YesNo
Postal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Manager
Facility Manager Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Roster Coordinator
Roster Coordinator Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Clinical Support
Clinical Support Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Unit/Ward Requirements
Number of Beds
MSU/Number of beds
Documentation System
Sign On Area
Gate Code
Parking
After Hours Contact Number

Area CodePhone Number
A/H RN on Duty
Invoicing

** Remittances are to be emailed through to accounts@carestaffnursing.com.au **
Invoice Contact Name

First NameLast Name
Invoice Contact Number

Area CodePhone Number
Invoice Email Address
example@example.com
Invoice Postal Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Payroll Tax Exempt
If yes, please click to complete form below:

QLD Payroll Tax Exemption Form

NSW Payroll Tax Exemption Form
Tax Exemption Form Upload

Cancelof
Any additional information
Notes
Authorisation
Name

First NameLast Name
Date

MonthDayYear
Date
Position
Signature

Clear
Should be Empty:

Facility Details