CARE PACK ORDER FORM
Please note that this form can only be used for in-patient admissions at a hospital or palliative care facility that has been approved by Derek's Place. If you would like to become an approved facility please contact info@dereksplace.org.au. We can register a facility and dispatch care packs within 48 hours.
This form must be completed by a team member from the hospital/palliative care facility. We cannot accept requests from other individuals.
Where should we send the packs?
Please provide your name and contact number
Please provide name, position and  phone number of the person who can take delivery of the packs (usually from the ward).
Room number of the patient receiving the packs.
Packs required:











When do you need the packs?
Other comments. If you need more than one of a particular pack, please let us know here.

Derek's Place Ltd
830 Victoria Road, Ryde, New South Wales, 2112