Wish Recipient Details

Lead Clinician (doctor in charge of care) Details

Eligibility

Each wish is individually assessed. Responses to the above questions will not affect consideration.

Final Wish request

Other Information

Final Wishes

  • The Ambulance Wish Western Australia service is volunteer run and all journeys are subject to the availability of volunteers.
  • A family member or carer can accompany the Wish Recipient in the Wish Ambulance.
  • The Wish Recipient must be able to consent to the Ambulance Wish.
  • The Final Wish request is not booked until you receive a phone call and/ or confirmation email.
By filling in this form you give Ambulance Wish Western Australia permission to use your personal data for the realisation of the last wish. This data will be kept securely in the archives of Ambulance Wish Western Australia for seven years.