Wish Request Form

Request a wish

Ambulance Wish Western Australia enable people receiving palliative care or who are terminally ill to fulfil a final wish by visiting a place of personal significance, for example, to admire their own garden, to feel the breeze of the beach or to be surrounded by their loved ones and pets.

Medically trained volunteers and adapted ambulances provide the means to make these last dreams come true.

To request a wish please complete the below full to the best of your knowledge. On successful submission, you should receive a copy of the submitted form. 

YOUR DETAILS

If applying for yourself, please leave blank.

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

Either type your date or click on the calendar.

ADDITIONAL INFORMATION

FINAL WISHES

* Ambulance Wish Western Australia is volunteer run and all journeys are subject to the availability of volunteers.

*A family member of carer can accompany the Wish Recipient in the Wish Ambulance.

*The Wish Recipient must be able to consent to the Final 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 final wish. This data will be kept securely in the archives of Ambulance Wish Western Australia for seven years.

Alternatively, complete a downloadable form and email it to Ambulance Wish Western Australia.

N.B. Downloadable forms received by email are processed during Monday to Friday office hours.