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

Your name
If applying for yourself, please leave blank.
Who should Ambulance Wish Western Australia contact regarding the final wish?
Preferred method of contact

WISH RECIPIENT DETAILS

Recipient name
Preferred pronouns
Address
Is the wish recipient receiving oxygen therapy?
Wish recipient weight
What is the wish recipient's current mobility?

LEAD CLINICIAN (DOCTOR IN CHARGE OF CARE) DETAILS

Clinician name

ELIGIBILITY

Wish recipient diagnosed with a life-limiting condition and/or a prognosis of less than 12 months
Wish recipient requires specialised transport to visit their place of personal significiance due to logistical/ transport barriers or medical needs?
Does the recipient have the approval of their lead clinician to undertake this journey?
Does the recipient have an Advanced Health Directive (AHD)/ Advance Care Plan/ Values & Preferences Form or similar?
Is there an Enduring Power of Guardianship / Guardianship Order in place for the wish recipient?
Has the Wish Recipient been approved under the WA VAD Act 2019?

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

FINAL WISH REQUEST

Do you have a preferred date or time for fulfilment of the wish?
Either type your date or click on the calendar. We do our very best to accommodate all requests, however, short notice wishes can sometimes be challenging to fulfil due to volunteer availability.

ADDITIONAL INFORMATION

Has a wish been previously requested for this person?
Do 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?
Wish recipients, or their authorised representatives, will be asked to sign an image consent form as part of the wish request process and Ambulance Wish Western Australia's Image consent policy.

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 confirmed until you receive a phone call and/ or email.

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 final wish. This data will be kept securely in the archives of Ambulance Wish Western Australia for seven years.