Western Care Lodge Booking Request Form

Title TitleMrMrsMsMissDrMxOther

Full Name

Mobile Phone Number

Home Phone Number

Email Address

Home Address

City/Town

State StateNSWQLDACTVICSAWANT

Postcode

Guest Room Type Guest Room Type Double Single Rollaway Bed ($20p/n) Hospitalised

CARER/NEXT OF KIN - Name

CARER/NEXT OF KIN - Contact Number

CARER/NEXT OF KIN - Relationship to Guest

Planned Check-in Date

Planned Check-out Date

Accommodation Type and Invoicing Details Accommodation Type and Invoicing DetailsCasual ($120p/n - less than 4 nights)IPTASS Bulk BillDepartment of Veteran AffairsCan AssistOther

Condition Being Treated For Condition Being Treated ForRadiotherapyChemotherapyBothOther

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