Please enable JavaScript in your browser to complete this form.Your Name: *FirstLastEmail: *Phone: *Relationship to Wish Recipient (if applying for yourself, please leave blank):Who should Ambulance Wish Western Australia contact regarding the final wish?Wish RecipientKey contact personBothPreferred Method of ContactEmailPhoneWish Recipient DetailsName: *FirstLastDate of Birth:Phone:Current address:Address Line 1Address Line 2CityState / Province / RegionPostal CodeWish Recipient WeightLess than 100 KgLess than 150 KgMore than 150 KgLead Clinician (doctor in charge of care) DetailsName:Email:Phone:EligibilityRecipient has a terminal diagnosis and is currently receiving palliative care or end-of-life care (as confirmed by their GP or treatment specialist)?YesNoUnsureDoes the Wish Recipient require specialised transport to visit their place of personal significance due to logistical or transport barriers? YesNoUnsureDoes the recipient have the approval of their lead clinician to undertake this journey?YesNoUnsureDoes the patient have an Advanced Health Care Directive (AHCD)?YesNoUnsureDoes the patient have complex healthcare needs?YesNoUnsure Each wish is individually assessed. Responses to the above questions will not affect consideration. Final Wish requestDesired location:Please provide us with some details of the final wish and its significance:Do you have a preferred date or time for fulfilment of the wish?DateTimeOther InformationAdditional Information:How did you hear about us?Have you previously requested a wish?NoYesDo you grant Ambulance Wish Western Australia permission to use images and/ or video recorded during the Final Wish to document the wish and promote Ambulance Wish Western Australia? YesNoFinal 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. Agreement *Yes, I agree to the wish conditions.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.Submit
