Gender/Pronouns Email Phone Number Street Address City State New South Wales Victoria Queensland Western Australia South Australia Tasmania Postal/Zip Code NDIS Number State New South Wales Victoria Queensland Western Australia South Australia Tasmania Relationship with the client How did you find out about Lotus Embrace Pty. Ltd.? Do you currently receive any nursing care services? If so, please describe: What specific nursing care services do you require from Lotus Embrace Pty. Ltd.? What are your goals or expectations from our nursing care services? Who or what do you turn to for support and resources related to your health and nursing care needs? Do you currently have a primary care physician or healthcare provider managing your medical needs? Are you currently taking any medications or receiving any treatments for your medical conditions? If yes, please provide details: Have you ever been hospitalized or undergone any surgeries related to your medical conditions? If yes, please provide details: Are you currently receiving therapy or counseling from any mental health professionals? If yes, please provide details: Do you have any other medical conditions or health concerns not mentioned above? If yes, please provide details: Are you vaccinated? If yes, please list the vaccines you have received. Do you have any known allergies? If yes, then please specify below. Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them. What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma etc.? I, undersigned, agree with the following statements: I acknowledge that I have been informed of the nature of the nursing care services provided and have had the opportunity to ask questions. I authorize Lotus Embrace Pty. Ltd. to deliver the specified nursing care services as outlined in my care plan to me or my dependant. I understand that it is my responsibility to inform the nursing care provider of any changes in my health status or circumstances that may affect the services provided. I understand that the information provided in this form will be used for the purpose of delivering nursing care services and will be treated confidentially. I understand that Lotus Embrace Pty. Ltd. may need to share my information with relevant parties, such as NDIS authorities, healthcare professionals, and other service providers, to ensure coordinated and effective service delivery. I release Lotus Embrace Pty. Ltd. from any liability for accidents, injuries, or adverse outcomes resulting from the provision of nursing care services, except in cases of negligence. I have the right to withdraw my consent at any time by notifying Lotus Embrace Pty. Ltd. in writing. However, this may impact the provision of NDIS services. I, (Client/Guardian of client), acknowledge that I have read and understood the terms outlined in this consent form and agree to receive services from Lotus Embrace. Date of form filled Send
