TOPDOCS

ADVANCE PERSONAL PLAN- NT
FULLSERVICEORDERFORM PAGE 1 OF 8

TOPDOCS.COM.AU

TOPDOCS

ADVANCE PERSONAL PLAN - NT

FULLSERVICEORDERFORM

To order yourAdvance Personal Plan-NTdocuments:

1.Complete all relevant fields in BLOCK LETTERS

2.Mail, fax or email this form to Topdocs –

Address: Suite 2, Level 2, 22 Albert Road South Melbourne VIC 3205; Fax: (03) 8256 0108;

Email: or

SECTION A (I): PERSON/ADVISER ORDERING DETAILS

Name: / Signature:
Company Name:
Postal Address:
Date Of Order: / / / Your Ref:
Phone: () - - / Fax: () - - / Email:

SECTION A (II): PAYMENT DETAILS

Enclosed is payment for the sum of: $
Direct Debit* / Visa / Mastercard / Cheque
Card Holder Name:
Credit Card Number: - - -
Expiry Date: / / Authorised Card Signature:

*TopaybyDirectDebityoumusthaveacurrentDirectDebitagreementwithTopdocs.IfyouwouldliketoarrangeforDirectDebitforfuture purchasespleasecontactTopdocson1300659242

SECTION B: DONOR

The Donor is the person who is appointing a decision maker under Advance Personal Plan.

Donor / Full Name:
Alias (if any):
Address:
Date of birth: / /

SECTION C (I): DECISION MAKER(S)

The Decision Maker(s) are the person or persons the Donor wishes to appoint as their substitute decision maker.

Decision Maker 1 / Full Name:
Alias (if any):
Address:
Telephone: () - -
Email:
Relationship to the Donor:
Matters: / all matters
OR
care or welfare matters (including health care)
OR
financial matters
OR
Note: You may limit the functions of your decision maker. If you do not wish to limit the functions of your decision maker, please leave the following section blank. We have provided some examples below. If required, you may select any of them. If you wish limit the functions of your decision maker to any other function(s), please contact us.
Limited matters - Financial
My decision maker may act only in relation to:
mysuperannuation matters
my property situated at (insert property address)
my bank accounts with(insert bank(s) name)
paying maintenance and accommodation expenses, including purchasing accommodation in whole
or in part, for me
including my dependents
paying my debts including any fees and expenses, rates, taxes, insurance premiums or other outgoings
Limited matters –care or welfare (including health care)
My decision maker’s power is limited to the following matters only:
To decide where I am to live, whether permanently or temporarily;
To decide with whom I am to live;
To decide what other kinds of personal services I receive.
To restrict visitors to such extent as may be necessary in my best interest and to prohibit visits by any person if my guardian reasonably believes that visits by that person would have an adverse effect on me.
Note: If you are limiting your decision maker’s power to only paying debts, expenses and / or maintenance and accommodation expenses etc., then ensure that the decision maker is also provided with access to funds to be able to do that (for example, access to bank accounts etc).
Decision Maker 2 / Full Name:
Alias (if any):
Address:
Telephone: () - -
Email:
Relationship to the Donor:
Matters: / all matters
OR
care or welfare matters (including health care)
OR
financial matters
OR
Note: You may limit the functions of your decision maker. If you do not wish to limit the functions of your decision maker, please leave the following section blank. We have provided some examples below. If required, you may select any of them. If you wish limit the functions of your decision maker to any other function(s), please contact us.
Limited matters - Financial
My decision maker may act only in relation to:
mysuperannuation matters
my property situated at (insert property address)
my bank accounts with(insert bank(s) name)
paying maintenance and accommodation expenses, including purchasing accommodation in whole
or in part, for me
including my dependents
paying my debts including any fees and expenses, rates, taxes, insurance premiums or other outgoings
Limited matters –care or welfare (including health care)
My decision maker’s power is limited to the following matters only:
To decide where I am to live, whether permanently or temporarily;
To decide with whom I am to live;
To decide what other kinds of personal services I receive.
To restrict visitors to such extent as may be necessary in my best interest and to prohibit visits by any person if my guardian reasonably believes that visits by that person would have an adverse effect on me.
Note: If you are limiting your decision maker’s power to only paying debts, expenses and / or maintenance and accommodation expenses etc., then ensure that the decision maker is also provided with access to funds to be able to do that (for example, access to bank accounts etc).
Decision Maker 3 / Full Name:
Alias (if any):
Address:
Telephone: () - -
Email:
Relationship to the Donor:
Matters: / all matters
OR
care or welfare matters (including health care)
OR
financial matters
OR
Note: You may limit the functions of your decision maker. If you do not wish to limit the functions of your decision maker, please leave the following section blank. We have provided some examples below. If required, you may select any of them. If you wish limit the functions of your decision maker to any other function(s), please contact us.
Limited matters - Financial
My decision maker may act only in relation to:
mysuperannuation matters
my property situated at (insert property address)
my bank accounts with(insert bank(s) name)
paying maintenance and accommodation expenses, including purchasing accommodation in whole
or in part, for me
including my dependents
paying my debts including any fees and expenses, rates, taxes, insurance premiums or other outgoings
Limited matters – care or welfare (including health care)
My decision maker’s power is limited to the following matters only:
To decide where I am to live, whether permanently or temporarily;
To decide with whom I am to live;
To decide what other kinds of personal services I receive.
To restrict visitors to such extent as may be necessary in my best interest and to prohibit visits by any person if my guardian reasonably believes that visits by that person would have an adverse effect on me.
Note: If you are limiting your decision maker’s power to only paying debts, expenses and / or maintenance and accommodation expenses etc., then ensure that the decision maker is also provided with access to funds to be able to do that (for example, access to bank accounts etc).
Decision Maker 4 / Full Name:
Alias (if any):
Address:
Telephone: () - -
Email:
Relationship to the Donor:
Matters: / all matters
OR
care or welfare matters (including health care)
OR
financial matters
OR
Note: You may limit the functions of your decision maker. If you do not wish to limit the functions of your decision maker, please leave the following section blank. We have provided some examples below. If required, you may select any of them. If you wish limit the functions of your decision maker to any other function(s), please contact us.
Limited matters - Financial
My decision maker may act only in relation to:
mysuperannuation matters
my property situated at (insert property address)
my bank accounts with(insert bank(s) name)
paying maintenance and accommodation expenses, including purchasing accommodation in whole
or in part, for me
including my dependents
paying my debts including any fees and expenses, rates, taxes, insurance premiums or other outgoings
Limited matters –care or welfare (including health care)
My decision maker’s power is limited to the following matters only:
To decide where I am to live, whether permanently or temporarily;
To decide with whom I am to live;
To decide what other kinds of personal services I receive.
To restrict visitors to such extent as may be necessary in my best interest and to prohibit visits by any person if my guardian reasonably believes that visits by that person would have an adverse effect on me.
Note: If you are limiting your decision maker’s power to only paying debts, expenses and / or maintenance and accommodation expenses etc., then ensure that the decision maker is also provided with access to funds to be able to do that (for example, access to bank accounts etc).

SECTION C (II): DECISION MAKERS TO ACT (IF MORE THAN 1 DECISION MAKER WITH OVERLAPPING AUTHORITY IN RELATION TO MATTERS)

Jointly
Severally
Jointly and Severally
Note: If you wish your decision makers to act in any other manner, please contact us.

SECTION D: APPOINTMENT OPTIONS FOR DECISION MAKER

Note: Decision makers may be appointed to act at all times, only in stated circumstances or at all times except in stated circumstances. We have provided some examples. If suitable, you may select any of them. If you wish to include other appointment options for your decisions maker(s), please contact us.
My decision maker number(s) and are appointed to act at all times.
My decision maker number(s) and shall only act as my decision maker in the event that my decision maker number is unable to continue in the role for any reason.
My decision maker number shall act as my primary decision maker and my decision maker number(s) and shall act as a secondary decision maker(s) for the times when my decision maker numbercannot be contacted.
My decision maker number shall act as my decision maker during the time
I live with him/her
he/she is living with me

SECTION E: RESTRICTIONS, REQUIREMENTS & DIRECTIONS

Note: Decision makers may be appointed subject to restrictions on authority, requirements to be complied with or specific directions. For example, “My decision makers are not authorised to invest in XYZ Pty Ltd shares” or “If I need nursing home care, I want my decision makers to try XYZ nursing home first” or “My decision maker must consult XYZ when making decisions in relation to my health care”.
If you do not wish to provide any restrictions, requirements or directions, please select ‘none’. Otherwise, we have provided some examples of restrictions, requirements and directions. If suitable, you may select any of them. If you wish to provide other restrictions, requirements or directions, please contact us.
None
OR
My decision maker must provide copies of all records and accounts in relation my financial matters to(name, address with of individual and relationship with the person making the advance personal plan) before.
My decision maker must provide details of all important decisions about my health care and welfare they have made to: (name, address with of individual and relationship with the person making the advance personal plan)
My decision maker must consult (name, address with of individual and relationship with the person making the advance personal plan) on any important decisions about my health and welfare.
Before agreeing to move me to a nursing home or facility, my decision maker must consult with:
(name, address, phone number, email of individual)
If I require long-term care in a facility outside my home,
I would prefer to live close to my(name, address with of individual and relationship with the person making the advance personal plan).
I want my attorney to try(insert name) nursing home first.

SECTION F: ADVANCE CARE DECISIONS

I: SPECIFIC HEALTH CARE TREATMENT DIRECTIONS
You may include specific health care treatment directions in your advance personal plan. If you do not wish to include any such directions, please leave the section blank.
It is strongly recommended that before completing this section you discuss your options with your doctor who knows your medical history and views. The doctor will also be able to explain any medical terms that you are unsure about and will confirm that you were able to understand the decisions you have made in the document and that you made those decisions voluntarily.
Life support / I would like life prolonging treatments to be commenced and continued, including CPR, while they are medically appropriate and remain in my best interests.
If I am acutely ill and unable to communicate responsively with my family and friends, and it is reasonably certain that I will not recover, I want to be allowed to die naturally and be cared for with dignity. I do not want to be kept alive by extraordinary or overly burdensome measures that might be used to prolong my life (eg Cardio-Pulmonary Resuscitation (CPR)). If any of these treatments have been started, I request that they be discontinued.
Palliative care / I do want palliative care that includes medications and other treatments to alleviate suffering and keep me comfortable.
II: OTHER SPECIFIC HEALTH CARE TREATMENT DIRECTIONS
You may list any treatment you would or would not want to have provided e.g. blood transfusions or antibiotics. We have provided some examples below. If suitable, you may select any of them. If you wish to include other treatments, please contact us. If you do not wish to list any treatments, please leave the section blank.
I do not want cardiopulmonary resuscitation (CPR)
I do not want blood transfusion
I do not wantblood products
I do not want assisted ventilation
I do not want assisted hydration
I do not want artificial nutrition
I do not want intensive care
I do not want intubation
I do not want antibiotics

SECTION G: ADVANCE CARE STATEMENT

I: GENERAL STATEMENTS OF VIEWS, WISHES AND BELIEFS
You may include in this section things that matter to you, which you think may be relevant when you can no longer speak for yourself. We have provided some examples below. If suitable, you may select any of them. If you wish to include other wishes, please contact us. If you do not wish to include any views, wishes and beliefs, please leave this section blank.
Being able to communicate with my family is very important to me.
To be treated with dignity by being kept clean and comfortable and having adequate pain management.
I desire that my attorney arrange for (insert relationship of the individual(s) with the appointor) to visit me on a regular basis.
I desire that my attorney arrange for me to attend (insert details of the activity or place) on a regular basis.
I: GOALS FOR END OF LIFE CARE (Include what you hope for most when you are near the end of your life. For example, family presence, access to items of significance, music, any personal, religious or cultural practices to be followed).
We have provided some examples below. If suitable, you may select any of them. If you wish to include other goals, please contact us. If you do not wish to include any goals for end of life, please leave this section blank.
If I am nearing death, I want the following:
All my family members to be present.
I do not wish to be present.
I desire (specify any other personal, religious or cultural practices)to be followed.

SECTION H: ADDITIONAL COMMENTS

Note: Your Advance Personal Plan allows you to make any comments in addition to the matters provided above. If you wish to include any additional comments in your Advance Personal Plan, please contact us.

SECTION I: REVOCATION OF POWER OF ATTORNEY

Do you have an existing Power of Attorney? / Yes ->
No / Location of POA:
Date of POA: / /
If YES, do you wish a Revocation of Power of Attorney to be prepared by Topdocs? / Yes
No