Treating clinician form

Patient's full name

Client's date of birth

What is their diagnosis and current condition?

Does the client have a terminal or life-limiting diagnosis?

Yes No

Is the client able to give written or verbal consent for their journey?

Yes No

Does the client require specialised medical transport to reach their destination?

Yes No Uncertain

Is the client on oxygen?

Yes No

Does the client have advanced care directives that specify not for resusitation?

Yes No Unsure

Is the client of normal weight for height, overweight or underweight?

Normal weight for height Overweight Underweight

If overweight, please provide approximate weight

Can the client transfer independently?

Yes, No

Can the client walk up and down a few steps?

Yes No With Assistance

How does the client mobilise?

Is the client continent and if no, please provide additional information

I approve that this client is able to travel on a Memory Lane journey

Yes, No

Name of treating clinician

Health care discipline of treating clinician

Contact number of treating clinician

Email of treating clinician

AHPRA registration number of treating clinician

Memory Lane treating clinician form