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Person Responsible

Where a consumer is at any stage unable to give directions or necessary consents to medical and other care, Montefiore may obtain such directions and consents from the ‘Person Responsible’ for the consumer. A Person Responsible is not necessarily the consumer’s next of kin.

A Person Responsible is either:

A guardian who has the function of consenting to medical, dental and health care treatments or, if there is no guardian
A spouse or de facto spouse with whom the person has a close, continuing relationship or, if there is no spouse or de facto spouse
An unpaid carer who is now providing support to the person or provided this support before the person entered residential care; or if there is no carer
A relative or friend who has a close personal relationship with the person

Person Responsible Information

Title

First Name

Last Name

Relationship to you

Address

Suburb

State

Postcode

e.g. 2174

Contact Numbers

Home

e.g. (02) 9123 6535

Work

e.g. 0412 345 678 or (02) 9123 6535

Mobile

e.g. 0412 345 678

Will the Person Responsible pay your accounts?

Title

First Name

Last Name

Relationship to you

Address

Suburb

State

Postcode

e.g. 2174

Contact Numbers

Home

e.g. (02) 9123 6535

Work

e.g. 0412 345 678 or (02) 9123 6535

Mobile

e.g. 0412 345 678

In the event of emergency please contact

An emergency is a significant change in the consumer's medical condition

Is the emergency contact same as the Person Responsible above?

Please provide emergency contact details

First Name

Last Name

Relationship to you

Address

Suburb

State

Postcode

e.g. 2174

Contact Numbers

Home

e.g. (02) 9123 6535

Work

e.g. 0412 345 678 or (02) 9123 6535

Mobile

e.g. 0412 345 678

Do you wish this person to be contact at any hour of the day or night?

During which hours do you wish this person to be contacted?

Start hour

Please enter 24 hr format

End Hour

Please enter 24 hr format

Do you wish to provide alternative contact details in case of emergency on Shabbat and High Holy days.

First Name

Last Name

Telephone number

e.g. (02) 9123 6535

General Practitioner

Phone

e.g. (02) 9123 6535

Address

Suburb

State

Postcode

e.g. 2174

Details of next of kin

This is the resident's closest living blood relative/s or relative/s by marriage/family.

NOK Child 1

First Name

Last Name

Occupation

Address

Suburb

State

Postcode

e.g. 2174

Contact Numbers

Home

e.g. (02) 9123 6535

Work

e.g. 0412 345 678 or (02) 9123 6535

Mobile

e.g. 0412 345 678

NOK Child 2

First Name

Last Name

Occupation

Address

Suburb

State

Postcode

e.g. 2174

Contact Numbers

Home

e.g. (02) 9123 6535

Work

e.g. 0412 345 678 or (02) 9123 6535

Mobile

e.g. 0412 345 678

NOK Child 3

First Name

Last Name

Occupation

Address

Suburb

State

Postcode

e.g. 2174

Contact Numbers

Home

e.g. (02) 9123 6535

Work

e.g. 0412 345 678 or (02) 9123 6535

Mobile

e.g. 0412 345 678

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Contact Information