kha big red kidney bus booking application v9...
TRANSCRIPT
Booking Information:
Big Red Kidney Bus Holiday Destination:
Yarrawonga (9 Nov to 12 Dec 2015) Melbourne (21 Dec 2015 to 30 Jan 2016)
Lakes Entrance (8 Feb to 26 March 2016) Mildura (4 April to 23 April 2016)
Echuca (2 May to 21 May 2016)
Halls Gap (5 Sept to 29 Oct 2016) Lorne (7 Nov to 17 Dec 2016) Melbourne (2 Jan to 28 Jan 2017) Lakes Entrance (6 Feb to 25 March 2017)
Holiday Dialysis Dates requested: Date in: _____ / _____ / _____ Date out: _____ / _____ / _____
Contact Details:
Title: __ First Name: ______________ Surname: ____________________ Date of Birth: ________
Postal Address: ____________________________________________________________________
Town/Suburb: _________________________________ State: ___________ Postcode: __________
Email: ___________________________________________________________________________
Mobile: _______________________________ Home Phone: _______________________________
Emergency Contact:
Name: ____________________________________________ Mobile: _______________________
Relationship:_____________________Email:____________________________________________
Admission Criteria: Please read the Monash Health Admission Criteria for the Big Red Kidney Bus, which can be found on our website. Dialysis on the Big Red Kidney Bus is not available for people with a permacath
Dialysis Days and Sessions: Please tick your preferred days and session times for dialysis Some flexibility may be requested by Monash Health
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
AM
PM
Holiday Accommodation (if known):
Address :__________________________________________________________________________
Mobile: _______________________________ Phone: _____________________________________
KHA OFFICE USE ONLY:
Date Received: _____________ Email Booking Phone Booking All information supplied Confirmation email sent
CRM Data Entered Processed by: __________________ Sent to Monash Health & Date sent:_________________________
Big Red Kidney Bus
Booking application to Kidney Health Australia
Booking number: _____________________
Confidential
Practitioner Details: Nephrologist
Name: _________________________________
Clinic or Hospital: ________________________
Address: _______________________________
Town/Suburb: ___________________________
State: ______________ Postcode: __________
Phone: _________________________________
General Practitioner
Name: _________________________________
Medical Clinic:___________________________
Address: _______________________________
Town/Suburb: ___________________________
State: ______________ Postcode: __________
Phone: _________________________________
Information: Medicare number: ________________ I am a public patient: YES
DVA (if applicable): _______________________
I am a private patient: YES
Health Fund name: ________________________
Health Fund number: ______________________
Hospital or Satellite Haemodialysis The Dialysis Unit I attend is: _______________________________________
Address: _______________________________
Town/Suburb: ___________________________
State: ______________ Postcode: __________
Nurse Unit Manager
Name: __________________________________
Telephone: ______________________________
Email: __________________________________
Parent Hospital: __________________________
Home Haemodialysis The name of my Home Haemodialysis Coordinator is:
_______________________________________
Hospital: _______________________________
Address: _______________________________
Town/Suburb: ___________________________
State: ______________ Postcode: __________
Telephone: ______________________________
Email: __________________________________
Parent Hospital: __________________________
Transport & Accommodation: I am aware that I need to arrange my own transport to and from the holiday destination and the Big Red Kidney Bus
YES NO
I am aware that I need to arrange and pay for my own accommodation in the local area where the Big Red Kidney Bus will be located
YES NO
Confirmation & Cancellation: I am aware that my booking application will be confirmed by Monash Health when I meet all of the criteria to have haemodialysis on the Big Red Kidney Bus. I will also receive the Monash Health Checklist of What to bring on the Bus
YES NO
If at any time I need to cancel a confirmed booking I will contact the Monash Health Big Red Kidney Bus Coordinator as soon as possible Lesley Ross Monash Health Big Red Kidney Bus Coordinator Mobile: 0408 784 433 Email: [email protected]
YES NO
Email completed application to [email protected] ( 1800 454 363