Name (First & Last)*
Address*
—Please choose an option—AustraliaNew ZealandUnited StatesUnited KingdomOther
Phone*
Email*
How many adults travelling?*
How many children travelling?*
Children's ages
Date of departure
Date returning
Budget for holiday
Destination
Please provide as much detail as possible to the following questions so we can ensure that you have the most comfortable trip possible.
Type of Disability
ParaplegiaQuadriplegiaOther
If other:
Who are you travelling with?
Alonewith a carerwith family/friends
Are you a Qantas Frequent Flyer member?
YesNo
If yes:
Do you have a NSW Companion Card?
Do you have a Qantas Carer Concession Card?
If you use a ventilator, have you obtained medical clearance to fly?
Do you require assistance to organise attendant care at your destination?
YesI am on the attendant care program.No
Service provider:
Primary means of mobility
Manual wheelchairPower wheelchairOther
Wheelchair dimensions
Width: Length: Weight:
Height when up: Collapsed:
Battery type
Dry cellWet cell
Travelling with medication? Please list:
Do you require assistance to transfer to an aircraft seat?
Yes, I need a hoist or 2 peopleYes, I need 1 personNo, I can transfer independently
Do you require an Upper Torso Harness?
Hoist Patient Lift
Travelling with my ownHire at destinationNot required
Hoist Weight:
Dimensions:
Sling Type: StandardWith head support
My Weight:
Shower Commode
Weight:
Toilet height:
Requirements: Side openingSelf propellingOther
Air Mattress
Requirements:
Other Equipment
Describe:
Accommodation
Do you require the bed at a certain height?
Do you need a roll-in shower?
Other shower/bathroom requirements:
Do you have any other requirements? What else can we assist you with?
