how to receive meals

Meals on Wheels (SA) Inc provides an in home service for individuals (and their carers) who are not able to shop, prepare or cook meals for themselves.

Referral Details

Referred By*:

Referrer Title*:

Referrer First Name*:

Referrer Last Name*:

Referrer Phone Number*:

Referrer Email*:

Have you discussed this referral with the intended recipient or person responsible for the welfare of this person?*:

Yes
No

Client Details

Title*:

First Name*:

Last Name*:

Sex*:

Address*:

Suburb*:

Postcode*:

Phone Number*:

Birthdate*:

Reason for referral*:

Any other medical concerns we need to know about?:

Please note. All allergies to food must be accompanied by a doctors referral faxed or sent to MoW Central Office:

Please note. All allergies to food must be accompanied by a doctors referral faxed or sent to MoW Central Office

Are there any other issues MoW staff and volunteers need to know about to ensure their safety?:

Doctor's Name:

Doctor's Phone:

Meal Categories*:

** A Low Potassium Diet requires a medical referral and any Texture Modified meals must be accompanied by a Speech Pathology report before referral can be processed. Please send or fax details to Cental Office.* A Low Potassium Diet requires a medical referral and any Texture Modified meals must be accompanied by a Speech Pathology report before referral can be processed. Please send or fax details to Central Office.:

Alternate Contact Person

Contact Person's Title:

Contact Person's First Name:

Contact Person's Last Name:

Contact Person's Phone Number:

Does this person need to be present at the Assessment?*:

Yes
No

Extra Information

Any other details which would be useful for us to know:

* Required Fields

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how to receive meals