Consumer Information
Consumer
Name:
To collect common demographic and other essential
consumer information that can be shared with another
agency.
Date of Birth: dd/mm/yyyy
/
/
Sex:
UR Number:
or affix label here
Who the Agency Can Contact
if Necessary
Consumer Details
Family Name:
(e.g. carer, parent, case manager, next of kin, guardian,
friend, emergency contact)
Person 1 Name:
Contact Address
Given Names:
Preferred Name/s:
Date of Birth: dd/mm/yyyy
/
/
Post code:
Is the date of birth estimated?
Sex:
Code:
Code:
Phone numbers
Home:
Work:
Mobile:
Title:
Home Address
Relationship to Consumer:
Post code:
Post code:
Home: (
)
Yes
No
Work: (
)
Yes
No
Phone numbers
Home:
Work:
Mobile:
Mobile:
Yes
No
Relationship to Consumer:
Email:
Yes
No
Is this person the consumer’s carer?
Is this person the person who makes the
consumer’s legal decisions?
Code:
Indigenous Status:
Code:
Need for Interpreter Services:
Code:
Preferred Language:
Code:
Communication Method:
Code::
Code:
Post code:
Can leave message?
Country of Birth:
Code:
Consumer Information
Is this person the consumer’s carer?
Is this person the person who makes the
consumer’s legal decisions?
Person 2 Name:
Contact Address
Postal Address (if different from above)
Contact phone number/s
(tick preferred number)
Code:
General Practitioner
GP Name:
Practice Name:
Address:
Code:
Code:
Code:
Legal Orders:
Code:
Government Pension/Benefit Status:
Code:
Health Care Card Holder Status:
Card number:
Medicare Card:
Card number:
Health Insurance Status:
Insurer name:
Card number:
DVA Card Entitlement:
DVA card type:
DVA card number:
Code:
Compensables Funding Source:
Code:
Code:
Phone:
Comments:
Fax:
Email:
Produced by the Victorian Department of Human Services, 2009
This information collected by:
CI Page 1 of 1
Name:
Position/Agency:
Sign:
Date: dd/mm/yyyy
/
/
Contact number: