Book an Interpreter

Interpreter Booking Form
Patient's Name:
Deaf Consumer's Name: (if different from above)
Date of Birth: (Deaf Consumer)
Deaf Consumer's Contact Details:

Is the Deaf Consumer of Aboriginal or Torres Strait Islander origin?	No
	Yes - Aboriginal
	Yes - Torres Strait Islander
	Yes - Both

Deaf Consumer's Relationship to Patient:	Self
	Parent of
	Child Of
	Partner


Deaf Consumer's Mode of Communication:	Auslan (Australian Sign Language)
	Signed English
	Deaf/Blind Tactile
Name of Medical Professional:
Name of Surgery / Clinic:
Appointment Address:

Appointment Contact Phone No.:
Appointment Contact Fax No.:
Type of Medical Service?:
(i.e. GP, Specialist Doctor, Physiotherapy, Dentist, Mental Health etc.)

Date/s of Appointment:
Appointment Times:
Start Time:
Finish Time:
Preferred Interpreter: (if applicable)
Choice Number 1
Choice Number 2
Choice Number 3
Choice Number 4

Person filling in this form
Name:
Contact Details: (Phone, Fax, TTY, SMS, Email)
Relationship to Deaf Consumer:	Self Other

If other, please explain:

Security Number	Type the security number in the box below