Dereks Place Ltd | Derek's Place Ltd

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.

Requestor's information

Registering as

Individual Organisation

First name

Last name

Where should we send the packs?

Please provide name, position and phone number of the person who can take delivery of the packs (usually from the ward).

Surname and room number of the patient receiving the packs.

When do you need the packs?

Other comments. If you need more than one of a particular pack, please let us know here.
If you need a pack customised for a child we will do our best. Situations that may warrant customisation may include:
- A gender neutral pack has been requested by the family, or
- A child with special needs.
In these cases please include as much detail as possible about the needs of the child or children who will be receiving the pack and we will do our best.