COVID -19 Declaration
Have you had the COVID-19 Vaccine ?*
Yes - first doseYes - fully vaccinatedNo
Veteran Affairs and/or Workcover
Do they have a Department of Veteran Affairs card (DVA) or are under Workcover?*
If you answer NO to any of the following questions below, your client does not qualify to use our transport services. PLEASE DO NOT PROCEED FURTHER
Must be completed by a Medical Practitioner/Professional or Hospital based social worker.
Date of birth*
Purpose of Trip*
Will this be a regular trip? NoYes
Please enter any comments or additional information
This form must be completed by a Medical Organisation staff member / Medical Professional or Social Worker only.
Please click Ok to proceed