Participant Intake and Consent Form
Please complete this form so we can set up your care with Elvana Care. This information helps us understand your needs and stays confidential in line with our Privacy Policy. If you need help filling this in, call us on 0410 193 962 or email info@elvanacare.com.au.
Participant Details
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Street Address
*
Suburb
Please Select
Belconnen
Gungahlin
Inner North
Inner South
Woden Valley
Tuggeranong
Weston Creek
Queanbeyan
Karabar
Yass
Other
Postcode
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred contact method
Please Select
Phone
Mobile
Email
Text message
Medicare Number
Funding Type
Please Select
Support at Home (current program)
Home Care Package (legacy, transitioning)
Private pay / no funding in place
Not yet assessed / not sure
Support at Home classification level or Home Care Package level (if known)
My Aged Care ID
Current Provider
Representative/Nominee
Name
*
First Name
Middle Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Emergency Contact Name
*
First Name
Last Name
Relationship to Participant
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information
General Practitioner
Medical Conditions
Allergies
Current Medications
Mobility Aids
Diagnosis
Falls Risk
Other Clinical Information
Cultural & Communication Preferences
Interpreter Required
Yes
Aboriginal / Torres Strait Islander
Aboriginal
Torres Strait Islander
Both
Neither
Prefer not to say
Religion / Spiritual Preferences
Preferred language for interpreter
Communication / Accessibility Needs
Declaration & Signatures
I consent to Elvana Care collecting, using and storing my personal and health information for the purpose of providing care and services, in line with the Australian Privacy Principles.
*
Yes
No
I consent to Elvana Care sharing relevant information with my GP, My Aged Care, and other providers involved in my care, where necessary.
*
Yes
No
I agree that Elvana Care may take photos/videos of me for care records or (with separate permission) promotional use.
Yes
No
Participant/Representative Name
*
First Name
Middle Name
Last Name
Signature
*
leadSource
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: