Resident Application Form

A. Please Nominate The Palm Lake Caring Community
Location*
How did you hear about us?
B. Application Type
My Aged Care Client Referral Code
if applicable
Care Type*
Respite Start Date*
DD slash MM slash YYYY
Respite End Date*
DD slash MM slash YYYY
Are you transferring from another Aged Care Provider?
- Yes
Current Residential Agreement
Please provide Palm Lake Care with a copy of your current Residential Agreement or speak with our Care Solutions for assistance 1800 246 677.
Drop files here or

Max. file size: 20 MB.

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C. Applicant Details
Applicant's Name*
Title First Name Last Name
Preferred Name
Gender*
Date of Birth*
DD slash MM slash YYYY
Place of Birth
Nationality
Religion
Cultural Background
Preferred Language
Marital Status*
Smoker?*
Palm Lake Caring Communities are non smoking.
Home Address*
Street Address Address Line 2 City State Postcode Country
Contact Number*
Where are they now?*
Who is your treating GP?
Will your GP continue treating you in care?
- Yes
- No
GP practice address
GP practice phone
Does the potential resident currently have capacity to make their own decisions?
- Yes
- No
What clinical evidence is provided if no longer making their own decisions?

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D. Health Care Card Details
Pension / Concession Card Number

NB. A copy of this card will be required on admission
Pension Card Expiry
Pension Card Type
Medicare Card Number

NB. A copy of this card will be required on admission
Medicare Card Expiry
Private Health Fund?
- No
- Yes
Health Fund Name
Health Fund Number

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I. Application Checklist
Please make sure you have the following documentation (if applicable)
- Complete copy of ACAT Assessment
- Certified copy of Enduring Power of Attorney / Adult Guardianship Order / Public Trust Order
- Centrelink / DVA Income & Assets Assessment - 'Letter of Resident Status' (not required for respite)
- Copies of Pension / Medicare Cards
ACAT Referral Code
Upload any further supporting documents
You can also email these to caresolutions@palmlake.com.au
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Accepted file types: jpg, jpeg, pdf, png, doc, Max. file size: 5 MB.
Your comments
J. Declaration
In the event that a place is offered at your choice of Palm Lake Caring Communities, further personal and background information will be sought to ensure the highest standard of care. Refer to Palm Lake Care’s Privacy Policy for further details.
Declaration*
- I understand that if I do not submit a Combined Income and Asset Assessment form or if I submit one but it is completed incorrectly, I may be charged the maximum fees and charges as determined by the Department of Human Services (Centrelink).
Your Name*
First Last
Your Email Address*
Your Phone Number*
Your Signature
I sincerely declare that I have read and understood the information in this application form and that the answers to all the questions in regard to the financial details of myself, or on behalf of the applicant, and other information therein is to the best of my belief true and correct in every particular and is in no way false, inaccurate, incomplete, misleading or deceptive.
I agree that to allow the accurate determination of financial status of the applicant, I will provide further information or proof upon request.

Please use your mouse to sign this form.
Today's date: 09/08/2022
Name
This field is for validation purposes and should be left unchanged.

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Enquire Now

A. Please Nominate The Palm Lake Caring Community

B. Application Type

C. Applicant Details

D. Health Care Card Details

E. Nominated Representative Details (First Contact)

E. Nominated Representative Details (Second Contact)

Where would you like resident mail sent to?

F. Financial Information

G. Pension or Income Support

Income Source

H. Property Assets

Assets

I. Application Checklist

J. Declaration

Enquire Now

Search Palm Lake Care

Resident Application Form

A. Please Nominate The Palm Lake Caring Community

B. Application Type

C. Applicant Details

D. Health Care Card Details

E. Nominated Representative Details (First Contact)

E. Nominated Representative Details (Second Contact)

Where would you like resident mail sent to?

F. Financial Information

G. Pension or Income Support

Income Source

H. Property Assets

Assets

I. Application Checklist

J. Declaration